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Jouffroy R, Négrello F, Limery J, Gilbert B, Travers S, Bloch-Laine E, Ecollan P, Boularan J, Bounes V, Vivien B, Gueye P. The prehospital NEW score to assess septic shock in-hospital, 30-day and 90-day mortality. BMC Infect Dis 2024; 24:213. [PMID: 38365608 PMCID: PMC10873999 DOI: 10.1186/s12879-024-09104-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Accepted: 02/06/2024] [Indexed: 02/18/2024] Open
Abstract
BACKGROUND The early identification of sepsis presenting a high risk of deterioration is a daily challenge to optimise patient pathway. This is all the most crucial in the prehospital setting to optimize triage and admission into the appropriate unit: emergency department (ED) or intensive care unit (ICU). We report the association between the prehospital National Early Warning Score 2 (NEWS-2) and in-hospital, 30 and 90-day mortality of SS patients cared for in the pre-hospital setting by a mobile ICU (MICU). METHODS Septic shock (SS) patients cared for by a MICU between 2016, April 6th and 2021 December 31st were included in this retrospective cohort study. The NEWS-2 is based on 6 physiological variables (blood pressure, heart rate, respiratory rate, temperature, oxygen saturation prior oxygen supplementation, and level of consciousness) and ranges from 0 to 20. The Inverse Probability Treatment Weighting (IPTW) propensity method was applied to assess the association with in-hospital, 30 and 90-day mortality. A NEWS-2 ≥ 7 threshold was chosen for increased clinical deterioration risk definition and usefulness in clinical practice based on previous reports. RESULTS Data from 530 SS patients requiring MICU intervention in the pre-hospital setting were analysed. The mean age was 69 ± 15 years and presumed origin of sepsis was pulmonary (43%), digestive (25%) or urinary (17%) infection. In-hospital mortality rate was 33%, 30 and 90-day mortality were respectively 31% and 35%. A prehospital NEWS-2 ≥ 7 is associated with an increase in-hospital, 30 and 90-day mortality with respective RRa = 2.34 [1.39-3.95], 2.08 [1.33-3.25] and 2.22 [1.38-3.59]. Calibration statistic values for in-hospital mortality, 30-day and 90-day mortality were 0.54; 0.55 and 0.53 respectively. CONCLUSION A prehospital NEWS-2 ≥ 7 is associated with an increase in in-hospital, 30 and 90-day mortality of septic shock patients cared for by a MICU in the prehospital setting. Prospective studies are needed to confirm the usefulness of NEWS-2 to improve the prehospital triage and orientation to the adequate facility of sepsis.
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Affiliation(s)
- Romain Jouffroy
- Intensive Care Unit, Ambroise Paré Hospital- Assistance Publique Hôpitaux Paris, 9 avenue Charles De Gaulle, 92100, Boulogne-Billancourt, Paris, France.
- IRMES - Institute for Research in Medicine and Epidemiology of Sport, INSEP, Paris, France.
- INSERM U-1018, Centre de recherche en Epidémiologie et Santé des Populations - U1018 INSERM, Paris Saclay University, Villejuif, France.
- SAMU 972, Centre Hospitalier Universitaire de Martinique, Fort-de-France Martinique, France.
- UR5_3 PC2E, University of the Antilles, French West Indies, France.
| | - Florian Négrello
- SAMU 972, Centre Hospitalier Universitaire de Martinique, Fort-de-France Martinique, France
- UR5_3 PC2E, University of the Antilles, French West Indies, France
| | - Jean Limery
- SAMU 972, Centre Hospitalier Universitaire de Martinique, Fort-de-France Martinique, France
- UR5_3 PC2E, University of the Antilles, French West Indies, France
| | - Basile Gilbert
- Department of Emergency Medicine, SAMU 31, University Hospital of Toulouse, Toulouse, France
| | | | - Emmanuel Bloch-Laine
- Emergency Department, Cochin Hospital, Paris, France
- Emergency Department, SMUR, Hôtel Dieu Hospital, Paris, France
| | - Patrick Ecollan
- Intensive Care Unit, SMUR, Pitie Salpêtriere Hospital, 47 Boulevard de l'Hôpital, 75013, Paris, France
| | - Josiane Boularan
- Centre Hospitalier Intercommunal Castres-Mazamet, Castres, France
| | - Vincent Bounes
- Department of Emergency Medicine, SAMU 31, University Hospital of Toulouse, Toulouse, France
| | - Benoit Vivien
- Intensive Care Unit, Anaesthesiology, SAMU, Necker Enfants Malades Hospital, Assistance Publique - Hôpitaux de Paris, Paris, France
| | - Papa Gueye
- SAMU 972, Centre Hospitalier Universitaire de Martinique, Fort-de-France Martinique, France
- UR5_3 PC2E, University of the Antilles, French West Indies, France
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Jouffroy R, Holub M, Gilbert B, Travers S, Bloch-Laine E, Ecollan P, Bounes V, Boularan J, Vivien B, Gueye-Ngalgou P. Influence of antibiotic therapy with hemodynamic optimization on 30-day mortality among septic shock patients cared for in the prehospital setting. Am J Emerg Med 2024; 76:48-54. [PMID: 37995523 DOI: 10.1016/j.ajem.2023.11.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Revised: 10/23/2023] [Accepted: 11/07/2023] [Indexed: 11/25/2023] Open
Abstract
BACKGROUND In order to reduce septic shock mortality, international guidelines recommend early treatment implementation, antibiotic therapy (ABT) and hemodynamic optimisation, within 1-h. This retrospective multicentric study aims to investigate the relationship between prehospital ABT delivered within 1st hour and mean blood pressure (MAP) ≥ 65 mmHg at the end of the prehospital stage, and 30-day mortality among patients with septic shock. METHODS From May 2016 to December 2021, patients with septic shock requiring pre-hospital Mobile Intensive Care Unit intervention (MICU) were retrospectively analysed. To assess the relationship between 30-day mortality and prehospital ABT delivered within 1st hour and/or MAP ≥ 65 mmHg at the end of the prehospital stage, Inverse Probability Treatment Weighting (IPTW) propensity score method was performed. RESULTS Among the 530 patients included, 341 were male gender (64%) with a mean age of 69 ± 15 years. One-hundred and thirty-two patients (25%) patients received prehospital ABT, among which 98 patients (74%) were treated with 3rd generation cephalosporin. Suspected pulmonary, urinary and digestive infections were the cause of sepsis in respectively 43%, 25% and 17%. The 30-day overall mortality was 31%. A significant association was observed between 30-day mortality rate and (i) ABT administration within the first hour: RRa = 0.14 [0.04-0.55], (ii) ABT administration within the first hour associated with a MAP ≥ 65 mmHg: RRa = 0.08 [0.02-0.37] and (iii) ABT administration within the first hour in the prehospital setting associated with a MAP < 65 mmHg at the end of the prehospital stage: RRa = 0.75 [0.45-0.85]. Patients who received prehospital ABT after the first hour have also a 30-day mortality rate decrease: RRa = 0.87 [0.57-0.99], whereas patients who did not received ABT had an increased 30-day mortality rate: RRa = 2.36 [1.89-2.95]. CONCLUSION In this study, we showed that pre-hospital ABT within the first hour and MAP≥65 mmHg at the end of prehospital stage are both associated with 30-day mortality decrease among patients suffering from septic shock cared for by a MICU. Further prospective studies are needed to confirm these preliminary results.
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Affiliation(s)
- Romain Jouffroy
- Intensive Care Unit, Ambroise Paré Hospital, Assistance Publique - Hôpitaux de Paris, Boulogne Billancourt, France; Centre de recherche en Epidémiologie et Santé des Populations, U1018 INSERM, Paris Saclay University, France; EA 7329 - Institut de Recherche Médicale et d'Épidémiologie du Sport - Institut National du Sport, de l'Expertise et de la Performance, Paris, France.
| | - Matthieu Holub
- Intensive Care Unit, Ambroise Paré Hospital, Assistance Publique - Hôpitaux de Paris, Boulogne Billancourt, France
| | - Basile Gilbert
- Department of Emergency Medicine, SAMU 31, University Hospital of Toulouse, Toulouse, France
| | | | - Emmanuel Bloch-Laine
- Emergency Department, Cochin Hospital, Paris, France & Emergency Department, SMUR, Hôtel Dieu Hospital, Paris, France
| | - Patrick Ecollan
- Intensive Care Unit, SMUR, Pitie Salpêtriere Hospital, 47 Boulevard de l'Hôpital, Paris 75013, France
| | - Vincent Bounes
- Department of Emergency Medicine, SAMU 31, University Hospital of Toulouse, Toulouse, France
| | | | - Benoit Vivien
- Intensive Care Unit, Anaesthesiology, SAMU, Necker Enfants Malades Hospital, Assistance Publique - Hôpitaux de Paris, Paris, France
| | - Papa Gueye-Ngalgou
- SAMU 972 CHU de Martinique Pierre Zobda, Quitman Hospital, Fort-de-France Martinique, France
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Jouffroy R, Gille S, Gilbert B, Travers S, Bloch-Laine E, Ecollan P, Boularan J, Bounes V, Vivien B, Gueye P. RELATIONSHIP BETWEEN SHOCK INDEX, MODIFIED SHOCK INDEX, AND AGE SHOCK INDEX AND 28-DAY MORTALITY AMONG PATIENTS WITH PREHOSPITAL SEPTIC SHOCK. J Emerg Med 2024; 66:144-153. [PMID: 38336569 DOI: 10.1016/j.jemermed.2023.11.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 11/05/2023] [Accepted: 11/16/2023] [Indexed: 02/12/2024]
Abstract
BACKGROUND A relative hypovolemia occurs during septic shock (SS); the early phase is clinically reflected by tachycardia and low blood pressure. In the prehospital setting, simple objective tools to assess hypovolemia severity are needed to optimize triaging. OBJECTIVE The aim of this study was to evaluate the relationship between shock index (SI), diastolic SI (DSI), modified SI (MSI), and age SI (ASI) and 28-day mortality of patients with SS initially cared for in a prehospital setting of a mobile intensive care unit (MICU). METHODS From April 6, 2016 through December 31, 2021, 530 patients with SS cared for at a prehospital MICU were analyzed retrospectively. Initial SI, MSI, DSI, and ASI values, that is, first measurement after MICU arrival to the scene were calculated. A propensity score analysis with inverse probability of treatment weighting (IPTW) method was used to assess the relationship between SI, DSI, MSI, and ASI and 28-day mortality. RESULTS SS resulted mainly from pulmonary, digestive, and urinary infections in 44%, 25%, and 17% of patients. The 28-day overall mortality was 31%. IPTW propensity score analysis indicated a significant relationship between 28-day mortality and SI (adjusted odds ratio [aOR] 1.13; 95% CI 1.01-1.26; p = 0.04), DSI (aOR 1.16; 95% CI 1.06-1.34; p = 0.03), MSI (aOR 1.03; 95% CI 1.01-1.17; p = 0.03), and ASI (aOR 3.62; 95% CI 2.63-5.38; p < 10-6). CONCLUSIONS SI, DSI, MSI, and ASI were significantly associated with 28-day mortality among patients with SS cared for at a prehospital MICU. Further studies are needed to confirm the usefulness of SI and SI derivates for prehospital SS optimal triaging.
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Affiliation(s)
- Romain Jouffroy
- Intensive Care Unit, University Hospital Ambroise Paré, Assistance Publique-Hôpitaux de Paris, Boulogne Billancourt, France; Intensive Care Unit, Anaesthesiology, Service d'Aide Médicale Urgente, Necker Enfants Malades Hospital, Assistance Publique-Hôpitaux de Paris, Université de Paris, Paris, France; EA 7329-Institut de Recherche Médicale et d'Épidémiologie du Sport, Institut National du Sport, de l'Expertise et de la Performance, Paris, France
| | - Sonia Gille
- SAMU 972, University Hospital of Martinique, Pierre Zobda Quitman Hospital, Fort-de-France Martinique, France
| | - Basile Gilbert
- Department of Emergency Medicine, SAMU 31, University Hospital of Toulouse, Toulouse, France
| | | | - Emmanuel Bloch-Laine
- Emergency Department, Cochin Hospital, Paris, France; Emergency Department, Service Mobile d'Urgence et Reanimation, Hôtel Dieu Hospital, Paris, France
| | - Patrick Ecollan
- Intensive Care Unit, Service Mobile d'Urgence et Reanimation, La Pitié-Salpêtrière Hospital, Paris, France
| | | | - Vincent Bounes
- Department of Emergency Medicine, SAMU 31, University Hospital of Toulouse, Toulouse, France
| | - Benoît Vivien
- Intensive Care Unit, Anaesthesiology, Service d'Aide Médicale Urgente, Necker Enfants Malades Hospital, Assistance Publique-Hôpitaux de Paris, Université de Paris, Paris, France
| | - Papa Gueye
- SAMU 972, University Hospital of Martinique, Pierre Zobda Quitman Hospital, Fort-de-France Martinique, France
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Jouffroy R, Gilbert B, Tourtier JP, Bloch-Laine E, Ecollan P, Boularan J, Bounes V, Vivien B, Gueye P. Prehospital pulse pressure and mortality of septic shock patients cared for by a mobile intensive care unit. BMC Emerg Med 2023; 23:97. [PMID: 37626302 PMCID: PMC10464421 DOI: 10.1186/s12873-023-00864-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Accepted: 08/03/2023] [Indexed: 08/27/2023] Open
Abstract
BACKGROUND Septic shock medical treatment relies on a bundle of care including antibiotic therapy and hemodynamic optimisation. Hemodynamic optimisation consists of fluid expansion and norepinephrine administration aiming to optimise cardiac output to reach a mean arterial pressure of 65mmHg. In the prehospital setting, direct cardiac output assessment is difficult because of the lack of invasive and non-invasive devices. This study aims to assess the relationship between 30-day mortality and (i) initial pulse pressure (iPP) as (ii) pulse pressure variation (dPP) during the prehospital stage among patients cared for SS by a prehospital mobile intensive care unit (MICU). METHODS From May 09th, 2016 to December 02nd, 2021, septic shock patients requiring MICU intervention were retrospectively analysed. iPP was calculated as the difference between systolic blood pressure (SBP) and diastolic blood pressure (DBP) at the first contact between the patient and the MICU team prior to any treatment and, dPP as the difference between the final PP (the difference between SBP and DBP at the end of the prehospital stage) and iPP divided by prehospital duration. To consider cofounders, the propensity score method was used to assess the relationship between (i) iPP < 40mmHg, (ii) positive dPP and 30-day mortality. RESULTS Among the 530 patients analysed, pulmonary, digestive, and urinary infections were suspected among 43%, 25% and 17% patients, respectively. The 30-day overall mortality rate reached 31%. Cox regression analysis showed an association between 30-day mortality and (i) iPP < 40mmHg; aHR of 1.61 [1.03-2.51], and (ii) a positive dPP; aHR of 0.56 [0.36-0.88]. CONCLUSION The current study reports an association between 30-day mortality rate and iPP < 40mmHg and a positive dPP among septic shock patients cared for by a prehospital MICU. A negative dPP could be helpful to identify septic shock with higher risk of poor outcome despite prehospital hemodynamic optimization.
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Affiliation(s)
- Romain Jouffroy
- Intensive Care Unit, Ambroise Paré Hospital, Assistance Publique Hôpitaux Paris and Paris Saclay University, 9 avenue Charles De Gaulle, Boulogne-Billancourt, 92100, France.
- Intensive Care Unit, Anaesthesiology, SAMU, Necker Enfants Malades Hospital, Assistance Publique - Hôpitaux Paris, Paris, France.
- Centre de recherche en Epidémiologie et Santé des Populations - U1018 INSERM, Paris Saclay University, Villejuif, France.
- Institut de Recherche bioMédicale et d'Epidémiologie du Sport - EA7329, INSEP - Paris University, Paris, France.
- EA 7525 Université des Antilles, Fort de France, France.
| | - Basile Gilbert
- Department of Emergency Medicine, SAMU 31, University Hospital of Toulouse, Toulouse, France
| | | | - Emmanuel Bloch-Laine
- Emergency Department, Cochin Hospital, Paris, France
- Emergency Department, SMUR, Hôtel Dieu Hospital - Assistance Publique - Hôpitaux Paris, Paris, France
| | - Patrick Ecollan
- Intensive Care Unit, SMUR, Pitie Salpêtriere Hospital, 47 Boulevard de l'Hôpital, Paris - Assistance Publique - Hôpitaux Paris, Paris, 75013, France
| | - Josiane Boularan
- SAMU 31, Centre Hospitalier Intercommunal Castres-Mazamet, Castres, France
| | - Vincent Bounes
- Department of Emergency Medicine, SAMU 31, University Hospital of Toulouse, Toulouse, France
| | - Benoit Vivien
- Intensive Care Unit, Anaesthesiology, SAMU, Necker Enfants Malades Hospital, Assistance Publique - Hôpitaux Paris, Paris, France
| | - Papa Gueye
- EA 7525 Université des Antilles, Fort de France, France
- SAMU 972, Centre Hospitalier Universitaire de Martinique, Fort-de-France Martinique, France
- EA 7525 University of the Antilles, Martinique, France
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Jouffroy R, Ecollan P, Chollet-Xemard C, Prunet B, Elie C, Treluyer JM, Vivien B. Evaluation of the effectiveness of potassium chloride in the management of out-of hospital cardiac arrest by refractory ventricular fibrillation: Study protocol of the POTACREH study. PLoS One 2023; 18:e0284429. [PMID: 37043520 PMCID: PMC10096226 DOI: 10.1371/journal.pone.0284429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Accepted: 10/10/2022] [Indexed: 04/13/2023] Open
Abstract
PURPOSE Out-of-hospital cardiac arrest (OHCA) has a poor prognosis, with an overall survival rate of about 5% at discharge. Shockable rhythm cardiac arrests (ventricular fibrillation (VF) and pulseless ventricular tachycardia (VT)) have a better prognosis. In case of shockable rhythm, treatment is based on defibrillation, and thereafter, in case of failure of 3 external electric shocks (EES), on direct intravenous administration of 300 mg amiodarone, or lidocaine when amiodarone is unavailable or inefficient. During surgical procedures under extracorporeal circulation, a high potassium cardioplegia solution is administered to interrupt cardiac activity and facilitate surgical procedure. By extension, direct intravenous administration of potassium chloride (KCl) has been shown to convert VF, resulting in return to a hemodynamically efficient organized heart rate within a few minutes. The aim of this study is to provide clinical evidence that direct intravenous injection of KCl, into a patient presenting with OHCA due to refractory VF although 3 EES, should interrupt this VF and then allow rapid restauration of an organized heart rhythm, and thus return of spontaneous circulation (ROSC). METHODS A multicenter, prospective, single group, phase 2 study will be conducted on 81 patients presenting with refractory VF. After failure of 3 EES, each patient will receive direct intravenous injection of 20 mmol KCl instead of amiodarone. The primary outcome will be survival rate at hospital admission. Major secondary outcomes will include ROSC and time to ROSC in the prehospital setting, number of VF recidivism after KCl injection, survival rate at hospital discharge with a good neurologic prognostic, and survival rate 3 months after hospital discharge with a good neurologic prognostic. RESULTS No patient is currently included in the study. DISCUSSION Conventional guideline strategy based on antiarrhythmic drug administration, i.e. amiodarone or lidocaine, for OHCA due to shockable rhythm, has not yet demonstrated an increase in survival at hospital admission or at hospital discharge. This may be related to the major cardiodepressant effect of those drugs. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT04316611. Registered on March 2020. AP-HP180577 / N° EUDRACT: 2019-002544-24. Funded by the French Health Ministry. https://clinicaltrials.gov/ct2/show/NCT04316611.
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Affiliation(s)
- Romain Jouffroy
- SAMU de Paris, Service d’Anesthésie-Réanimation, Hôpital Universitaire Necker—Enfants Malades, APHP Centre, Assistance Publique—Hôpitaux de Paris and Université de Paris, Paris, France
| | - Patrick Ecollan
- SMUR Pitié Salpêtrière, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique—Hôpitaux de Paris, Paris, France
| | - Charlotte Chollet-Xemard
- SAMU du Val de Marne, Hôpitaux Universitaires Henri Mondor, Assistance Publique—Hôpitaux de Paris, Créteil, France
| | | | - Caroline Elie
- URC Cochin, Assistance Publique—Hôpitaux de Paris, Paris, France
| | | | - Benoit Vivien
- SAMU de Paris, Service d’Anesthésie-Réanimation, Hôpital Universitaire Necker—Enfants Malades, APHP Centre, Assistance Publique—Hôpitaux de Paris and Université de Paris, Paris, France
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Jouffroy R, Parfait PA, Gilbert B, Tourtier JP, Bloch-Laine E, Ecollan P, Boularan J, Bounes V, Vivien B, Gueye PN. Relationship between prehospital modified Charlson Comorbidity Index and septic shock 30-day mortality. Am J Emerg Med 2022; 60:128-133. [DOI: 10.1016/j.ajem.2022.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Revised: 07/31/2022] [Accepted: 08/02/2022] [Indexed: 10/15/2022] Open
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Jouffroy R, Gilbert B, Thomas L, Bloch-Laine E, Ecollan P, Boularan J, Bounes V, Vivien B, Gueye PN. Association between prehospital shock index variation and 28-day mortality among patients with septic shock. BMC Emerg Med 2022; 22:87. [PMID: 35590250 PMCID: PMC9118768 DOI: 10.1186/s12873-022-00645-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2021] [Accepted: 04/13/2022] [Indexed: 11/10/2022] Open
Abstract
PURPOSE Septic shock (SS) hyperdynamic phase is characterized by tachycardia and low-blood pressure reflecting the relative hypovolemia. Shock index (SI), the ratio between heart rate and systolic blood pressure, is a simple objective tool, usable for SS prognosis assessment. This study aims to evaluate the relationship between prehospital SI variation and 28-day mortality of SS patients initially cared for in prehospital setting by a mobile intensive care unit (mICU). METHODS From April 6th, 2016 to December 31st, 2020, 406 patients with SS requiring prehospital mICU were retrospectively analyzed. Initial SI, i.e. first measurement after mICU arrival to the scene, and final SI, i.e. last measurement of the prehospital stage, were used to calculate delta SI (initial SI-final SI) and to define positive and negative delta SI. A survival analysis after propensity score matching compared the 28-day mortality of SS patients with positive/negative delta SI. RESULTS The main suspected origins of infection were pulmonary (42%), digestive (25%) and urinary (17%). The 28-day overall mortality reached 29%. Cox regression analysis revealed a significant association between 28-day mortality and delta SI. A negative delta SI was associated with an increase in mortality (adjusted hazard ratio (HRa) of 1.88 [1.07-3.31] (p = 0.03)), whereas a positive delta SI was associated with a mortality decrease (HRa = 0.53 [0.30-0.94] (p < 10-3)). CONCLUSION Prehospital hemodynamic delta SI among SS patients cared for by a mICU is associated with 28-day mortality. A negative prehospital delta SI could help physicians to identify SS with higher risk of 28-day mortality.
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Affiliation(s)
- Romain Jouffroy
- Intensive Care Unit, Ambroise Paré Hospital, Assistance Publique - Hôpitaux de Paris, Paris, France. .,IRMES - Institute for Research in Medicine and Epidemiology of Sport, INSEP, Paris, France. .,INSERM U-1018, Centre de Recherche en Epidémiologie Et Santé Des Populations - U1018 INSERM, Paris Saclay University, Paris, France. .,Université de Paris, 7329, Paris, EA, France. .,Intensive Care Unit, Anaesthesiology, SAMU, Necker Enfants Malades Hospital, Assistance Publique - Hôpitaux de Paris, Paris, France.
| | - Basile Gilbert
- Department of Emergency Medicine, University Hospital of Toulouse, SAMU 31, Toulouse, France
| | - Léa Thomas
- Hôpital d'Instruction Des Armées Bégin, Paris, France
| | - Emmanuel Bloch-Laine
- Emergency Department, Cochin Hospital, Paris, France & Emergency Department, SMUR, Hôtel Dieu Hospital, Paris, France
| | - Patrick Ecollan
- Intensive Care Unit, SMUR, Pitie Salpêtriere Hospital, 47 Boulevard de l'Hôpital, 75013, Paris, France
| | | | - Vincent Bounes
- Department of Emergency Medicine, University Hospital of Toulouse, SAMU 31, Toulouse, France
| | - Benoit Vivien
- Intensive Care Unit, Anaesthesiology, SAMU, Necker Enfants Malades Hospital, Assistance Publique - Hôpitaux de Paris, Paris, France
| | - Papa-Ngalgou Gueye
- SAMU 972 CHU de Martinique Pierre Zobda Quitman Hospital, Fort-de-France Martinique, France
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Jouffroy R, Hajjar A, Gilbert B, Tourtier JP, Bloch-Laine E, Ecollan P, Boularan J, Bounes V, Vivien B, Gueye PN. Prehospital norepinephrine administration reduces 30-day mortality among septic shock patients. BMC Infect Dis 2022; 22:345. [PMID: 35387608 PMCID: PMC8988327 DOI: 10.1186/s12879-022-07337-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2021] [Accepted: 02/21/2022] [Indexed: 11/23/2022] Open
Abstract
Background Despite differences in time of sepsis recognition, recent studies support that early initiation of norepinephrine in patients with septic shock (SS) improves outcome without an increase in adverse effects. This study aims to investigate the relationship between 30-day mortality in patients with SS and prehospital norepinephrine infusion in order to reach a mean blood pressure (MAP) > 65 mmHg at the end of the prehospital stage. Methods From April 06th, 2016 to December 31th, 2020, patients with SS requiring prehospital Mobile Intensive Care Unit intervention (MICU) were retrospectively analysed. To consider cofounders, the propensity score method was used to assess the relationship between prehospital norepinephrine administration in order to reach a MAP > 65 mmHg at the end of the prehospital stage and 30-day mortality.
Results Four hundred and seventy-eight patients were retrospectively analysed, among which 309 patients (65%) were male. The mean age was 69 ± 15 years. Pulmonary, digestive, and urinary infections were suspected among 44%, 24% and 17% patients, respectively. One third of patients (n = 143) received prehospital norepinephrine administration with a median dose of 1.0 [0.5–2.0] mg h−1, among which 84 (69%) were alive and 38 (31%) were deceased on day 30 after hospital-admission. 30-day overall mortality was 30%. Cox regression analysis after the propensity score showed a significant association between prehospital norepinephrine administration and 30-day mortality, with an adjusted hazard ratio of 0.42 [0.25–0.70], p < 10–3. Multivariate logistic regression of IPTW retrieved a significant decrease of 30-day mortality among the prehospital norepinephrine group: ORa = 0.75 [0.70–0.79], p < 10–3.
Conclusion In this study, we report that prehospital norepinephrine infusion in order to reach a MAP > 65 mmHg at the end of the prehospital stage is associated with a decrease in 30-day mortality in patients with SS cared for by a MICU in the prehospital setting. Further prospective studies are needed to confirm that very early norepinephrine infusion decreases septic shock mortality.
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Affiliation(s)
- Romain Jouffroy
- Intensive Care Unit, Ambroise Paré Hospital, Assistance Publique Hôpitaux Paris and Paris Saclay University, 9 avenue Charles de Gaulle, 92100, Boulogne-Billancourt, France. .,Intensive Care Unit, Anaesthesiology, SAMU, Necker Enfants Malades Hospital, Assistance Publique, Hôpitaux Paris, Paris, France. .,Centre de Recherche en Epidémiologie et Santé des Populations, U1018 INSERM, Paris Saclay University, Paris, France. .,Institut de Recherche bioMédicale et d'Epidémiologie du Sport, EA7329, INSEP, Paris University, Paris, France. .,EA 7525 Université des Antilles, Pointe-à-Pitre, France.
| | - Adèle Hajjar
- Intensive Care Unit, Ambroise Paré Hospital, Assistance Publique Hôpitaux Paris and Paris Saclay University, 9 avenue Charles de Gaulle, 92100, Boulogne-Billancourt, France
| | - Basile Gilbert
- Department of Emergency Medicine, SAMU 31, University Hospital of Toulouse, Toulouse, France
| | | | - Emmanuel Bloch-Laine
- Emergency Department, Cochin Hospital, Paris, France.,Emergency Department, SMUR, Hôtel Dieu Hospital, Assistance Publique, Hôpitaux Paris, Paris, France
| | - Patrick Ecollan
- Intensive Care Unit, SMUR, Pitie Salpêtriere Hospital, Assistance Publique, Hôpitaux Paris, 47 Boulevard de l'Hôpital, 75013, Paris, France
| | - Josiane Boularan
- SAMU 31, Centre Hospitalier Intercommunal Castres-Mazamet, Castres, France
| | - Vincent Bounes
- Department of Emergency Medicine, SAMU 31, University Hospital of Toulouse, Toulouse, France
| | - Benoit Vivien
- Intensive Care Unit, Anaesthesiology, SAMU, Necker Enfants Malades Hospital, Assistance Publique, Hôpitaux Paris, Paris, France
| | - Papa-Ngalgou Gueye
- EA 7525 Université des Antilles, Pointe-à-Pitre, France.,SAMU 972 University Hospital of Martinique, Fort-de-France, Martinique, France
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Gil-Jardiné C, Jabre P, Adnet F, Nicol T, Ecollan P, Guihard B, Ferdynus C, Bocquet V, Combes X. Correction to: Incidence and factors associated with out-of-hospital peri-intubation cardiac arrest: a secondary analysis of the CURASMUR trial. Intern Emerg Med 2022; 17:619. [PMID: 35150391 DOI: 10.1007/s11739-022-02941-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Cédric Gil-Jardiné
- Department of Emergency, CHU de Bordeaux, Place Amélie Raba Léon, 33076, Bordeaux cedex, France
| | - Patricia Jabre
- AP-HP, Service d'Aide Médicale d'Urgence (SAMU) de Paris and Paris Sudden Death Expertise Center, Université Paris Descartes, Paris, France
- Department of Anesthesia and Critical Care-SAMU, Assistance Publique-Hôpitaux de Paris, Hôpital Necker-Enfants Malades, Université Paris Descartes, 149 rue de Sèvres, 75015, Paris, France
| | - Frederic Adnet
- Urgences-SAMU 93, Unite Recherche-Enseignement-Qualite, Hopital Avicenne, Bobigny, France
| | - Thomas Nicol
- Department of Anesthesia and Critical Care-SAMU, Assistance Publique-Hôpitaux de Paris, Hôpital Necker-Enfants Malades, Université Paris Descartes, 149 rue de Sèvres, 75015, Paris, France
| | - Patrick Ecollan
- Department of Anesthesia and Critical Care-SAMU, Assistance Publique-Hôpitaux de Paris, Hôpital Necker-Enfants Malades, Université Paris Descartes, 149 rue de Sèvres, 75015, Paris, France
| | - Bertrand Guihard
- Department of Emergency, CHU de la Réunion, Université de La Réunion, Réunion, France
| | - Cyril Ferdynus
- INSERM CIC 1410 Clinical and Epidemiology/CHU Réunion/Université de la Réunion, Saint-Pierre, Reunion, France
| | - Valery Bocquet
- Departement d'Informatique Clinique, Centre Hospitalier Universitaire de La Réunion Site Félix Guyon, Saint-Denis, France
| | - Xavier Combes
- Department of Emergency, CHU de Bordeaux, Place Amélie Raba Léon, 33076, Bordeaux cedex, France.
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Gil-Jardiné C, Jabre P, Adnet F, Nicol T, Ecollan P, Guihard B, Ferdynus C, Bocquet V, Combes X. Incidence and factors associated with out-of-hospital peri-intubation cardiac arrest: a secondary analysis of the CURASMUR trial. Intern Emerg Med 2022; 17:611-617. [PMID: 35037125 DOI: 10.1007/s11739-021-02903-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Accepted: 11/27/2021] [Indexed: 11/25/2022]
Abstract
The Incidence of peri-intubation cardiac arrest (PICA) has been rarely assessed in the out-of-hospital setting. The objectives of this study were to assess the incidence and factors associated with PICA (cardiac arrest occurring within 15 min of intubation) in an out-of-hospital emergency setting, wherein emergency physicians perform standardized airway management using a rapid sequence intubation technique in adult patients. This was a secondary analysis of the "Succinylcholine versus Rocuronium for out-of-hospital emergency intubation" (CURASMUR) trial, which compared the first attempt intubation success rate between succinylcholine and rocuronium in adult patients requiring emergency tracheal intubation for any vital distress except cardiac arrest. Enrollment occurred from January 2014 to August 2016 in 17 French out-of-hospital emergency medical units. All operators were emergency physicians. The PICA incidence was recorded and multivariable logistic regression analysis was used to identify the factors associated with its occurrence. A total of 1226 patients were included with a mean age of 55.9 ± 19 years. PICA was recorded in 35 (2.8%) patients. Multivariable analysis indicated that the occurrence of PICA was independently associated with a body mass index (BMI) > 30 kg m2 [adjusted odds ratio (aOR) 4.85; 95% confidence interval (CI) 1.82-12.90, p = 0.02], oxygen saturation (SpO2) before intubation < 90% (aOR 3.4; 95% CI 1.50-7.60, p = 0.003), difficult intubation (defined by an Intubation Difficulty Score [IDS] > 5, [aOR 3.59; 95% CI 1.82-8.08, p = 0.02], the use of rocuronium instead of succinylcholine (aOR 2.47; 95% CI 1.08-5.64, p = 0.03), post intubation hypoxaemia (aOR 2.70; 95% CI 1.05-6.95, p = 0.04), post-intubation hypotension (aOR 4.07; 95% CI 1.62-10.22, p = 0.003), and pulmonary aspiration(aOR 4.78; 95% CI 1.48-15.36, p = 0.009). Early PICA occurred in approximately 3% of cases in the out-of-hospital setting. We identified several independent risk factors for PICA, including obesity, hypoxaemia before intubation and difficult intubation.
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Affiliation(s)
- Cédric Gil-Jardiné
- Department of Emergency, CHU de Bordeaux, Place Amélie Raba Léon, 33076, Bordeaux cedex, France
| | - Patricia Jabre
- AP-HP, Service d'Aide Médicale d'Urgence (SAMU) de Paris and Paris Sudden Death Expertise Center, Université Paris Descartes, Paris, France
- Department of Anesthesia and Critical Care-SAMU, Assistance Publique-Hôpitaux de Paris, Hôpital Necker-Enfants Malades, Université Paris Descartes, 149 rue de Sèvres, 75015, Paris, France
| | - Frederic Adnet
- Urgences-SAMU 93, Unite Recherche-Enseignement-Qualite, Hopital Avicenne, Bobigny, France
| | - Thomas Nicol
- Department of Anesthesia and Critical Care-SAMU, Assistance Publique-Hôpitaux de Paris, Hôpital Necker-Enfants Malades, Université Paris Descartes, 149 rue de Sèvres, 75015, Paris, France
| | - Patrick Ecollan
- Department of Anesthesia and Critical Care-SAMU, Assistance Publique-Hôpitaux de Paris, Hôpital Necker-Enfants Malades, Université Paris Descartes, 149 rue de Sèvres, 75015, Paris, France
| | - Bertrand Guihard
- Department of Emergency, CHU de la Réunion, Université de La Réunion, Réunion, France
| | - Cyril Ferdynus
- INSERM CIC 1410 Clinical and Epidemiology/CHU Réunion/Université de la Réunion, Saint-Pierre, Reunion, France
| | - Valery Bocquet
- Departement d'Informatique Clinique, Centre Hospitalier Universitaire de La Réunion Site Félix Guyon, Saint-Denis, France
| | - Xavier Combes
- Department of Emergency, CHU de Bordeaux, Place Amélie Raba Léon, 33076, Bordeaux cedex, France.
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Jouffroy R, Gilbert B, Hassan A, Tourtier JP, Bloch-Laine E, Ecollan P, Boularan J, Bounes V, Vivien B, Gueye P. Adequacy of probabilistic prehospital antibiotic therapy for septic shock. Am J Emerg Med 2021; 53:80-85. [PMID: 34995860 DOI: 10.1016/j.ajem.2021.12.062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Revised: 12/22/2021] [Accepted: 12/23/2021] [Indexed: 10/19/2022] Open
Abstract
BACKGROUND Guidelines on sepsis management recommend early recognition, diagnosis and treatment, especially early antibiotic therapy (ABT) administration in order to reduce septic shock (SS) mortality. However, the adequacy of probabilistic prehospital ABT remains unknown. METHODS From May 2016 to March 2021, all consecutive patients with SS cared for by a prehospital mICU intervention were retrospectively analyzed. RESULTS Among 386 patients retrospectively analyzed, 119 (33%) received probabilistic prehospital ABT, among which 74% received a 3rd generation cephalosporin: 31% cefotaxime and 42% ceftriaxone. No patient had a serious adverse effect related to ABT administration. Overall mortality rate on day-30 was 29%. Among the 119 patients with prehospital ABT, bacteriological identification was obtained for 81 (68%) patients with adequate prehospital ABT for 65 patients (80%) of which 10 (15%) deceased on day-30. Conversely, among the 16 (20%) patients with inadequate prehospital ABT, 9 patients (56%) were deceased on day-30. Prehospital adequate ABT was significantly different between alive and deceased patients on day-30 (p = 4.10-3). After propensity score matching, a significant association between adequate prehospital ABT administration and day-30 mortality was observed (aOR = 0.09 [0.01-0.47]). Inverse probability treatment weighting with multivariable logistic regression reported a day-30 mortality decrease in the adequate prehospital ABT group: aOR = 0.70 [0.53-0.93]. CONCLUSIONS Among SS cared for by a mICU, probabilistic prehospital ABT is adequate most of the time and associated with a day-30 mortality decrease. Further prospective studies are needed to confirm these results and the weight of prehospital ABT in the prehospital bundle of care for SS.
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Affiliation(s)
- Romain Jouffroy
- Intensive Care Unit, University Hospital Ambroise Paré, Boulogne Billancourt, France; Intensive Care Unit, Anaesthesiology, SAMU, Necker Enfants Malades Hospital, Assistance Publique - Hôpitaux de Paris, Université de Paris, Paris, France; Centre de recherche en Epidémiologie et Santé des Populations, U1018 INSERM, Université Paris Saclay, France; Institut de Recherche bioMédicale et d'Epidémiologie du Sport - EA7329, INSEP, Université de Paris, France; EA 7525 Université des Antilles, France.
| | - Basile Gilbert
- Department of Emergency Medicine, SAMU 31, University Hospital of Toulouse, Toulouse, France; Paris Fire Brigade, Paris, France
| | - Anna Hassan
- Intensive Care Unit, University Hospital Ambroise Paré, Boulogne Billancourt, France
| | - Jean-Pierre Tourtier
- Emergency Department, Cochin Hospital, Paris, France; Emergency Department, SMUR, Hôtel Dieu Hospital, Paris, France
| | - Emmanuel Bloch-Laine
- Intensive Care Unit, SMUR, Pitie Salpêtriere Hospital, 47 Boulevard de l'Hôpital, 75013 Paris, France
| | | | - Josiane Boularan
- SAMU 972 University Hospital of Martinique, Fort-de-France, Martinique, France
| | - Vincent Bounes
- Department of Emergency Medicine, SAMU 31, University Hospital of Toulouse, Toulouse, France; Paris Fire Brigade, Paris, France
| | - Benoit Vivien
- Intensive Care Unit, Anaesthesiology, SAMU, Necker Enfants Malades Hospital, Assistance Publique - Hôpitaux de Paris, Université de Paris, Paris, France
| | - Papa Gueye
- EA 7525 Université des Antilles, France; SAMU 972 University Hospital of Martinique, Fort-de-France, Martinique, France
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12
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Jouffroy R, Gilbert B, Tourtier JP, Bloch-Laine E, Ecollan P, Bounes V, Boularan J, Léguillier T, Gueye-Ngalgou P, Vivien B. Impact of Prehospital Antibiotic Therapy on Septic Shock Mortality. PREHOSP EMERG CARE 2021; 25:317-324. [PMID: 32352890 DOI: 10.1080/10903127.2020.1763532] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Accepted: 04/28/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND Septic shock (SS) is associated with high morbidity and mortality rate. Early antibiotic therapy administration in septic patients was shown to reduce mortality but its impact on mortality in a prehospital setting is still under debate. To clarify this point, we performed a retrospective analysis on patients with septic shock who received antibiotics in a prehospital setting. Methods: From April 15th, 2017 to March 1st, 2020, patients with septic shock requiring Mobile Intensive Care Unit (MICU) intervention were retrospectively analyzed to assess the impact of prehospital antibiotic therapy administration on a 30-day mortality. Results: Three-hundred-eight patients with septic shock requiring MICU intervention in the prehospital setting were analyzed. The mean age of the study population was 70 ± 15 years. Presumed origin of SS was mainly pulmonary (44%), digestive (21%) or urinary (19%) infection. Overall 30-day mortality was 29%. Ninety-eight (32%) patients received antibiotic therapy. Using Cox regression analysis, we showed that prehospital antibiotic therapy significantly reduces 30-day mortality for patients with septic shock (hazard ratio = 0.56, 95%CI [0.35-0.89], p = 0.016). Conclusion: In this retrospective study, prehospital antibiotic therapy reduces 30-day mortality of septic shock patients cared for by MICU. Further studies will be needed to confirm the beneficial effect of prehospital antibiotic therapy in association or not with prehospital hemodynamic optimization to improve the survival of septic shock patients.
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Nicol T, Gil-Jardiné C, Jabre P, Adnet F, Ecollan P, Guihard B, Ferdynus C, Combes X. Incidence, Complications, and Factors Associated with Out-of-Hospital First Attempt Intubation Failure in Adult Patients: A Secondary Analysis of the CURASMUR Trial Data. PREHOSP EMERG CARE 2021; 26:280-285. [PMID: 33595420 DOI: 10.1080/10903127.2021.1891357] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Objectives: The objectives of this study were to evaluate first attempt intubation failure rate, its associated factors, and its related complications in out-of-hospital emergency setting, when emergency physicians perform standardized airway management using rapid sequence intubation in adult patients. Material and methods: The present study was a substudy of the Succinylcholine versus Rocuronium for out-of-hospital Emergency Intubation (CURASMUR) Trial, which compared Succinylcholine and Rocuronium used for Rapid sequence intubation. First attempt Intubation failure rate and early intubation related complications were recorded. We used multivariable logistic regression analysis to determine first intubation failure associated factors. Results: A total of 1230 patients were included with mean age of 55.9 +/- 19 years. First attempt intubation failure was recorded in 285 (23.2%) patients. The occurrence of a first attempt intubation failure was independently associated with history of ear, nose, and throat neoplasia (OR 2.20, CI 95% 1.06-4.60). Early intubation related complications were more frequent in case of first attempt intubation failure: 80 of 285 (28.4%) in patients with first attempt intubation failure and 185 of 945 (19.6%) in patients with successful first attempt intubation [OR 1.44; CI 95%, 1.11-1.87]. Conclusion: Based on a large multicenter study on out-of-hospital tracheal intubation of adult patients, we found that first attempt intubation failure rate was high and that history of ear, nose, and throat (ENT) neoplasia was an independent associated factor. Failure in first intubation attempt was associated with significantly more intubation related complications.
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Tavenier AH, Hermanides RS, Fabris E, Lapostolle F, Silvain J, ten Berg JM, Lassen JF, Bolognese L, Cantor WJ, Cequier Á, Chettibi M, Goodman SG, Hammett CJ, Huber K, Janzon M, Merkely B, Storey RF, Zeymer U, Ecollan P, Collet JP, Willems FF, Diallo A, Vicaut E, Hamm CW, Montalescot G, van 't Hof AWJ. Efficacy and Safety of Glycoprotein IIb/IIIa Inhibitors on Top of Ticagrelor in STEMI: A Subanalysis of the ATLANTIC Trial. Thromb Haemost 2019; 120:65-74. [DOI: 10.1055/s-0039-1700546] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Abstract
Background Glycoprotein IIb/IIIa inhibitors (GPIs) in combination with clopidogrel improve clinical outcome in ST-elevation myocardial infarction (STEMI); however, finding a balance that minimizes both thrombotic and bleeding risk remains fundamental. The efficacy and safety of GPI in addition to ticagrelor, a more potent P2Y12-inhibitor, have not been fully investigated.
Methods 1,630 STEMI patients who underwent primary percutaneous coronary intervention (PCI) were analyzed in this subanalysis of the ATLANTIC trial. Patients were divided in three groups: no GPI, GPI administration routinely before primary PCI, and GPI administration in bailout situations. The primary efficacy outcome was a composite of death, myocardial infarction, urgent target revascularization, and definite stent thrombosis at 30 days. The safety outcome was non-coronary artery bypass graft (CABG)-related PLATO major bleeding at 30 days.
Results Compared with no GPI (n = 930), routine GPI (n = 525) or bailout GPI (n = 175) was not associated with an improved primary efficacy outcome (4.2% no GPI vs. 4.0% routine GPI vs. 6.9% bailout GPI; p = 0.58). After multivariate analysis, the use of GPI in bailout situations was associated with a higher incidence of non-CABG-related bleeding compared with no GPI (odds ratio [OR] 2.96, 95% confidence interval [CI] 1.32–6.64; p = 0.03). However, routine GPI use compared with no GPI was not associated with a significant increase in bleeding (OR 1.78, 95% CI 0.88–3.61; p = 0.92).
Conclusion Use of GPIs in addition to ticagrelor in STEMI patients was not associated with an improvement in 30-day ischemic outcome. A significant increase in 30-day non-CABG-related PLATO major bleeding was seen in patients who received GPIs in a bailout situation.
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Affiliation(s)
| | | | - Enrico Fabris
- Cardiovascular Department, University of Trieste, Trieste, Italy
| | | | - Johanne Silvain
- ACTION Study Group, Pitié-Salpêtrière Hospital (AP-HP), Sorbonne University, Paris, France
| | - Jurrien M. ten Berg
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Jens F. Lassen
- Department of Cardiology, Odense University Hospital, Odense, Denmark
| | - Leonardo Bolognese
- Cardiovascular Department, Azienda Ospedaliera, Toscana Sudest, Arezzo, Italy
| | - Warren J. Cantor
- Division of Cardiology, Southlake Regional Health Centre, University of Toronto, Toronto, Canada
| | - Ángel Cequier
- Heart Disease Institute, Bellvitge University Hospital, IDIBELL, University of Barcelona, Barcelona, Spain
| | | | - Shaun G. Goodman
- Terrence Donnelly Heart Centre, St. Michael's Hospital, University of Toronto, Toronto, Canada
| | | | - Kurt Huber
- 3rd Department of Medicine, Cardiology and Intensive Care Medicine, Wilhelminenspital , Medical School, Sigmund Freud University, Vienna, Austria
| | - Magnus Janzon
- Department of Cardiology, Linköping University, Linköping, Sweden
- Department of Medical and Health Sciences, Linköping University, Linköping, Sweden
| | - Béla Merkely
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Robert F. Storey
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom
| | - Uwe Zeymer
- Klinikum Ludwigshafen und Institut für Herzinfarktforschung, Ludwigshafen, Germany
| | - Patrick Ecollan
- ACTION Study Group, Pitié-Salpêtrière Hospital (AP-HP), Sorbonne University, Paris, France
| | - Jean-Phillipe Collet
- ACTION Study Group, Pitié-Salpêtrière Hospital (AP-HP), Sorbonne University, Paris, France
| | | | - Abdourahmane Diallo
- ACTION Study Group, Statistical Unit, Lariboisière Hospital (AP-HP), Paris VII University, Paris, France
| | - Eric Vicaut
- ACTION Study Group, Statistical Unit, Lariboisière Hospital (AP-HP), Paris VII University, Paris, France
| | | | - Gilles Montalescot
- ACTION Study Group, Pitié-Salpêtrière Hospital (AP-HP), Sorbonne University, Paris, France
| | - Arnoud W. J. van 't Hof
- Department of Cardiology, Isala, Zwolle, The Netherlands
- Department of Cardiology, Zuyderland Medical Center, Heerlen, The Netherlands
- Department of Cardiology, Maastricht University Medical Center, Maastricht, The Netherlands
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15
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Collet JP, Kerneis M, Lattuca B, Yan Y, Cayla G, Silvain J, Lapostolle F, Ecollan P, Diallo A, Vicaut E, Hamm CW, Van 't Hof AW, Montalescot G. Impact of age on the effect of pre-hospital P2Y12 receptor inhibition in primary percutaneous coronary intervention for ST-segment elevation myocardial infarction: the ATLANTIC-Elderly analysis. EUROINTERVENTION 2018; 14:789-797. [PMID: 29969431 DOI: 10.4244/eij-d-18-00182] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
AIMS The aim of the study was to examine the main results of the ATLANTIC trial in patients with ST-elevation myocardial infarction (STEMI), randomised to pre- versus in-hospital ticagrelor, according to age. METHODS AND RESULTS Patients were evaluated by age class (<75 vs. ≥75 years) for demographics, prior cardiovascular history, risk factors, management, and outcomes. Elderly patients (≥75 years; 304/1,862) were more likely to be women, diabetic, lean, with a prior history of myocardial infarction and CABG, and with comorbidities (p<0.01 for all). Elderly patients presented more frequently with acute heart failure and less frequently had thromboaspiration, a stent implanted (p<0.01) and an aggressive antithrombotic regimen. Elderly patients had lower rates of pre- and post-PCI ≥70% ST-segment elevation resolution (43.9% vs. 51.6%; p=0.035), of pre- and post-PCI TIMI 3 flow (17.1% vs. 27.5%, p=0.0002), and a higher rate of the composite of death/MI/stroke/urgent revascularisation (9.9% vs. 2.9%; OR 3.67, 95% CI [2.27; 5.93], p<0.0001) and mortality (8.5% vs. 1.5%; OR 6.45, 95% CI [2.75; 15.11], p<0.0001). There was a non-significant trend towards more frequent major bleedings among elderly patients (TIMI major 2.3% vs. 1.1%; OR 2.13, 95% CI [0.88; 5.18], p=0.095). There was no significant interaction between time of ticagrelor administration (pre-hospital versus in-lab) and class of age for all outcomes. CONCLUSIONS Elderly patients, who represented one sixth of the patients randomised in the ATLANTIC trial, had less successful mechanical reperfusion and a sixfold increase in mortality at 30 days, probably due to comorbidities and possible undertreatment. The effect of early ticagrelor was consistent irrespective of age.
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Affiliation(s)
- Jean-Philippe Collet
- Sorbonne Université Paris 6, ACTION Study Group, Hôpital Pitié-Salpêtrière (AP-HP), Paris, France
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16
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Beygui F, Van Belle E, Ecollan P, Machecourt J, Hamm CW, Lopez De Sa E, Flather M, Verheugt FWA, Vicaut E, Zannad F, Pitt B, Montalescot G. Individual participant data analysis of two trials on aldosterone blockade in myocardial infarction. Heart 2018; 104:1843-1849. [PMID: 29695512 DOI: 10.1136/heartjnl-2018-312950] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2018] [Revised: 03/26/2018] [Accepted: 03/28/2018] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND Two recent randomised trials studied the benefit of mineralocorticoid receptor antagonists (MRAs) in ST-segment elevation myocardial infarction (STEMI) irrespective or in absence of heart failure. The studies were both undersized to assess hard clinical endpoints. A pooled analysis was preplanned by the steering committees. METHODS We conducted a prespecified meta-analysis of patient-level data of patients with STEMI recruited in two multicentre superiority trials, randomised within 72 hours after symptom onset. Patients were allocated (1:1) to two MRA regimens: (1) an intravenous bolus of potassium canrenoate (200 mg) followed by oral spironolactone (25 mg once daily) versus standard therapy or (2) oral eplerenone (25-50 mg) versus placebo. The primary and key secondary outcomes, all-cause death and the composite of all-cause death or resuscitated sudden death, respectively, were assessed in the intention-to-treat population using a Cox model stratified on the study identifier. RESULTS Patients were randomly assigned to receive (n=1118) or not the MRA regimen (n=1123). After a median follow-up time of 188 days, the primary and secondary outcomes occurred in 5 (0.4%) and 17 (1.5%) patients (adjusted HR (adjHR) 0.31, 95% CI 0.11 to 0.86, p=0.03) and 6 (0.5%) and 22 (2%) patients (adjHR 0.26, 95% CI 0.10 to 0.65, p=0.004) in the MRA and control groups, respectively. There were also trends towards lower rates of cardiovascular death (p=0.06) and ventricular fibrillation (p=0.08) in the MRA group. CONCLUSION Our analysis suggests that compared with standard therapy, MRA regimens are associated with a reduction of death and death or resuscitated sudden death in STEMI.
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Affiliation(s)
- Farzin Beygui
- ACTION Study Group, Service de Cardiologie, Centre Hospitalier Universitaire de Caen, EA4650 Normandie Université, Caen, Basse-Normandie, France
| | - Eric Van Belle
- INSERM U1011 and Cardiology, Institut Coeur Poumon, CHRU de Lille, Lille, France
| | - Patrick Ecollan
- SAMU, ACTION Study Group, Centre Hospitalier Universitaire Pitié-Salpêtrière, Paris, France
| | - Jacques Machecourt
- Service de Cardiologie, Centre Hospitalier Universitaire de Grenoble, Grenoble, Rhône-Alpes, France
| | | | | | - Marcus Flather
- Cardiology, University of East Anglia and Norfolk and Norwich University Hospital, Norwich, UK
| | | | - Eric Vicaut
- ACTION Study Group, Unite de Recherche Clinique, Hôpital Lariboisière, Paris, France
| | - Faiez Zannad
- Inserm CIC 1433 and Cardiology, Centre Hospitalier Universitaire de Nancy, Vandœuvre-lès-Nancy, France
| | - Bertram Pitt
- University of Michigan Hospital, Ann Arbor, Michigan, USA
| | - Gilles Montalescot
- Cardiology, Sorbonne Université-Paris 6, ACTION Study Group, Institut de Cardiologie (AP-HP), Centre Hospitalier Universitaire Pitié-Salpêtriėre, INSERM UMRS 1166, Paris, France
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17
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Cayla G, Lapostolle F, Ecollan P, Stibbe O, Benezet JF, Henry P, Hammett CJ, Lassen JF, Storey RF, Ten Berg JM, Hamm CW, Van't Hof AW, Montalescot G. Pre-hospital ticagrelor in ST-segment elevation myocardial infarction in the French ATLANTIC population. Int J Cardiol 2017. [PMID: 28622941 DOI: 10.1016/j.ijcard.2017.06.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND ATLANTIC was a randomized study comparing pre- and in-hospital treatment with a ticagrelor loading dose (LD) in ongoing ST-segment elevation myocardial infarction (STEMI). We sought to compare patient characteristics and clinical outcomes in France with other countries participating in ATLANTIC. METHODS The population comprised 1862 patients, 660 (35.4%) from France and 1202 from 12 other countries. The main endpoints were reperfusion (≥70% ST-segment elevation resolution) and TIMI flow grade 3 before (co-primary endpoints) and after percutaneous coronary intervention (PCI). Other endpoints included a composite ischaemic endpoint (death/myocardial infarction/stroke/urgent revascularization/definite stent thrombosis) and bleeding events at 30days. RESULTS In France, median times from first LD to angiography and between first and second LDs were 49 and 35min, respectively, and were similar to other countries. French patients were younger (mean 58.7 vs 61.9years, p<0.0001) and characterized by a higher rate of radial access (89.9% vs 54.8%, p<0.0001), more frequent use of pre-hospital glycoprotein (GP) IIb/IIIa inhibitors (14.1% vs 3.1%, p<0.0001) and intravenous enoxaparin (57.3% vs 10.1%, p<0.0001). In France, as in other countries, the co-primary endpoints did not differ between the two randomization groups. The composite ischaemic endpoint was numerically lower in France (3.3% vs 5.1%, p=0.07), with a lower mortality (1.4% vs 3.3%, p=0.01). PLATO major bleeding was numerically less frequent in France (1.8% vs 3.2%, p=0.07). CONCLUSIONS The French population appears to have better outcomes than the rest of the study population, and seems related to differences in demographics and management characteristics. TRIAL REGISTRY ClinicalTrials.gov (NCT01347580).
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Affiliation(s)
- Guillaume Cayla
- Department of Cardiology, CHU Caremeau, Université de Montpellier, Nîmes, France.
| | | | | | | | | | | | - Christopher J Hammett
- Department of Cardiology, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - Jens Flensted Lassen
- Department of Cardiology B, Aarhus University Hospital, Skejby, Aarhus N, Denmark
| | - Robert F Storey
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
| | - Jur M Ten Berg
- Department of Cardiology, St Antonius Hospital Nieuwegein, Nieuwegein, Netherlands
| | - Christian W Hamm
- Department of Cardiology, Kerckhoff Heart Center, Bad Neuheim, Germany
| | | | - Gilles Montalescot
- Sorbonne Université Paris 6, ACTION Study Group, Institut de Cardiologie (AP-HP), CHU Pitié-Salpêtrière, INSERM UMRS, 1166 Paris, France
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Beygui F, Cayla G, Roule V, Roubille F, Delarche N, Silvain J, Van Belle E, Belle L, Galinier M, Motreff P, Cornillet L, Collet JP, Furber A, Goldstein P, Ecollan P, Legallois D, Lebon A, Rousseau H, Machecourt J, Zannad F, Vicaut E, Montalescot G. Early Aldosterone Blockade in Acute Myocardial Infarction: The ALBATROSS Randomized Clinical Trial. J Am Coll Cardiol 2016; 67:1917-27. [PMID: 27102506 DOI: 10.1016/j.jacc.2016.02.033] [Citation(s) in RCA: 73] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2015] [Revised: 02/12/2016] [Accepted: 02/15/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND Mineralocorticoid receptor antagonists (MRA) improve outcome in the setting of post-myocardial infarction (MI) heart failure (HF). OBJECTIVES The study sought to assess the benefit of an early MRA regimen in acute MI irrespective of the presence of HF or left ventricular (LV) dysfunction. METHODS We randomized 1,603 patients to receive an MRA regimen with a single intravenous bolus of potassium canrenoate (200 mg) followed by oral spironolactone (25 mg once daily) for 6 months in addition to standard therapy or standard therapy alone. The primary outcome of the study was the composite of death, resuscitated cardiac arrest, significant ventricular arrhythmia, indication for implantable defibrillator, or new or worsening HF at 6-month follow-up. Key secondary/safety outcomes included death and other individual components of the primary outcome and rates of hyperkalemia at 6 months. RESULTS The primary outcome occurred in 95 (11.8%) and 98 (12.2%) patients in the treatment and control groups, respectively (hazard ratio [HR]: 0.97; 95% confidence interval [CI]: 0.73 to 1.28). Death occurred in 11 (1.4%) and 17 (2.1%) patients in the treatment and control groups, respectively (HR: 0.65; 95% CI: 0.30 to 1.38). In a non-pre-specified exploratory analysis, the odds of death were reduced in the treatment group (3 [0.5%] vs. 15 [2.4%]; HR: 0.20; 95% CI: 0.06 to 0.70) in the subgroup of ST-segment elevation MI (n = 1,229), but not in non-ST-segment elevation MI (p for interaction = 0.01). Hyperkalemia >5.5 mmol/l(-1) occurred in 3% and 0.2% of patients in the treatment and standard therapy groups, respectively (p < 0.0001). CONCLUSIONS The study failed to show the benefit of early MRA use in addition to standard therapy in patients admitted for MI. (Aldosterone Lethal effects Blockade in Acute myocardial infarction Treated with or without Reperfusion to improve Outcome and Survival at Six months follow-up; NCT01059136).
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Affiliation(s)
- Farzin Beygui
- ACTION Study Group, Service de Cardiologie, Centre Hospitalier Universitaire de Caen, Caen, France
| | - Guillaume Cayla
- ACTION Study Group, Service de Cardiologie, Centre Hospitalier Universitaire de Nimes, Nîmes, France
| | - Vincent Roule
- ACTION Study Group, Service de Cardiologie, Centre Hospitalier Universitaire de Caen, Caen, France
| | - François Roubille
- Service de Cardiologie, Centre Hospitalier Universitaire de Montpellier, Montpellier, France
| | | | - Johanne Silvain
- ACTION Study Group, Institut de Cardiologie (AP-HP), Centre Hospitalier Universitaire Pitié-Salpêtriėre, Paris, France
| | - Eric Van Belle
- Service de Cardiologie, Centre Hospitalier Universitaire de Lille, Lille, France
| | - Loic Belle
- Service de Cardiologie, Centre Hospitalier d'Annecy, Annecy, France
| | - Michel Galinier
- Service de Cardiologie, Centre Hospitalier Universitaire de Toulouse, Toulouse, France
| | - Pascal Motreff
- Service de Cardiologie, Centre Hospitalier Universitaire de Clermont Ferrand, Clermont Ferrand, France
| | - Luc Cornillet
- ACTION Study Group, Service de Cardiologie, Centre Hospitalier Universitaire de Nimes, Nîmes, France
| | - Jean-Philippe Collet
- ACTION Study Group, Institut de Cardiologie (AP-HP), Centre Hospitalier Universitaire Pitié-Salpêtriėre, Paris, France
| | - Alain Furber
- Service de Cardiologie, Centre Hospitalier Universitaire d'Angers, Angers, France
| | - Patrick Goldstein
- Service d'Accueil des Urgences et SAMU, Centre Hospitalier Universitaire de Lille, Lille, France
| | - Patrick Ecollan
- ACTION Study Group, SAMU, Centre Hospitalier Universitaire Pitié-Salpêtrière, Paris, France
| | - Damien Legallois
- ACTION Study Group, Service de Cardiologie, Centre Hospitalier Universitaire de Caen, Caen, France
| | - Alain Lebon
- ACTION Study Group, Service de Cardiologie, Centre Hospitalier Universitaire de Caen, Caen, France
| | - Hélène Rousseau
- ACTION Study Group, Unite de Recherche Clinique, Hôpital Lariboisière, Paris, France
| | - Jacques Machecourt
- Service de Cardiologie, Centre Hospitalier Universitaire de Grenoble, Grenoble, France
| | - Faiez Zannad
- INSERM, CIC 1433 et Pôle de Cardiologie, Centre Hospitalier Universitaire de Nancy, Nancy, France
| | - Eric Vicaut
- ACTION Study Group, Unite de Recherche Clinique, Hôpital Lariboisière, Paris, France
| | - Gilles Montalescot
- ACTION Study Group, Institut de Cardiologie (AP-HP), Centre Hospitalier Universitaire Pitié-Salpêtriėre, Paris, France.
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Cariou A, Deye N, Vivien B, Richard O, Pichon N, Bourg A, Huet L, Buleon C, Frey J, Asfar P, Legriel S, Narcisse S, Mathonnet A, Cravoisy A, Dequin PF, Wiel E, Razazi K, Daubin C, Kimmoun A, Lamhaut L, Marx JS, de la Garanderie DP, Ecollan P, Combes A, Spaulding C, Barat F, Ben Boutieb M, Coste J, Chiche JD, Pène F, Mira JP, Treluyer JM, Hermine O, Carli P. Early High-Dose Erythropoietin Therapy After Out-of-Hospital Cardiac Arrest: A Multicenter, Randomized Controlled Trial. J Am Coll Cardiol 2016; 68:40-9. [PMID: 27364049 DOI: 10.1016/j.jacc.2016.04.040] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2015] [Revised: 03/17/2016] [Accepted: 04/05/2016] [Indexed: 12/29/2022]
Abstract
BACKGROUND Preliminary data suggested a clinical benefit in treating out-of-hospital cardiac arrest (OHCA) patients with a high dose of erythropoietin (Epo) analogs. OBJECTIVES The authors aimed to evaluate the efficacy of epoetin alfa treatment on the outcome of OHCA patients in a phase 3 trial. METHODS The authors performed a multicenter, single-blind, randomized controlled trial. Patients still comatose after a witnessed OHCA of presumed cardiac origin were eligible. In the intervention group, patients received 5 intravenous injections spaced 12 h apart during the first 48 h (40,000 units each, resulting in a maximal dose of 200,000 total units), started as soon as possible after resuscitation. In the control group, patients received standard care without Epo. The main endpoint was the proportion of patients in each group reaching level 1 on the Cerebral Performance Category (CPC) scale (survival with no or minor neurological sequelae) at day 60. Secondary endpoints included all-cause mortality rate, distribution of patients in CPC levels at different time points, and side effects. RESULTS In total, 476 patients were included in the primary analysis. Baseline characteristics were similar in the 2 groups. At day 60, 32.4% of patients (76 of 234) in the intervention group reached a CPC 1 level, as compared with 32.1% of patients (78 of 242) in the control group (odds ratio: 1.01; 95% confidence interval: 0.68 to 1.48). The mortality rate and proportion of patients in each CPC level did not differ at any time points. Serious adverse events were more frequent in Epo-treated patients as compared with controls (22.6% vs. 14.9%; p = 0.03), particularly thrombotic complications (12.4% vs. 5.8%; p = 0.01). CONCLUSIONS In patients resuscitated from an OHCA of presumed cardiac cause, early administration of erythropoietin plus standard therapy did not confer a benefit, and was associated with a higher complication rate. (High Dose of Erythropoietin Analogue After Cardiac Arrest [Epo-ACR-02]; NCT00999583).
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Affiliation(s)
- Alain Cariou
- Medical Intensive Care Unit, Cochin Hospital (APHP), Paris, France; Paris Descartes University, Paris, France; INSERM U970 (team 4), Parisian Cardiovascular Research Center, Paris Descartes University, Paris, France.
| | - Nicolas Deye
- Medical Intensive Care Unit, Lariboisière Hospital (APHP) and INSERM U942, Paris, France
| | - Benoît Vivien
- Paris Descartes University, Paris, France; SAMU 75, Necker Hospital (AP-HP), Paris, France
| | - Olivier Richard
- SAMU 78, Centre Hospitalier de Versailles, Versailles, France
| | | | | | - Loïc Huet
- SAMU 94, Henri Mondor Hospital (APHP), Créteil, France
| | - Clément Buleon
- CHU de Caen, Pôle Réanimations, Anesthésie, SAMU, Caen, Caen, France
| | | | - Pierre Asfar
- Réanimation Médicale et de Médecine Hyperbare, CHU d'Angers, Angers, France
| | - Stéphane Legriel
- Medical ICU, Centre Hospitalier de Versailles, Versailles, France
| | | | - Armelle Mathonnet
- Medical-Surgical Intensive Care Unit, Hôpital de La Source, Centre Hospitalier Regional d'Orléans, Orléans, France
| | | | | | - Eric Wiel
- Emergency Department and SAMU 59, Lille University Hospital, Lille, France
| | - Keyvan Razazi
- Medical ICU, Hôpital Henri Mondor (APHP), Créteil, France
| | - Cédric Daubin
- CHU de Caen, Department of Medical Intensive Care, Caen, France
| | - Antoine Kimmoun
- Service de Réanimation Médicale Brabois, CHU de Nancy, Vandœuvres-les-Nancy, France
| | - Lionel Lamhaut
- INSERM U970 (team 4), Parisian Cardiovascular Research Center, Paris Descartes University, Paris, France; SAMU 75, Necker Hospital (AP-HP), Paris, France; Intensive Care Unit, Necker University Hospital (APHP), Paris, France
| | | | - Didier Payen de la Garanderie
- SMUR & Surgical Intensive Care, Lariboisière University Hospital (APHP) and Paris 7 University Denis Diderot, Paris, France
| | | | - Alain Combes
- Medical Intensive Care Unit, INSERM, UMRS-1166, Université Pierre et Marie Curie, iCAN, Institute of Cardiometabolism and Nutrition, Hôpital de la Pitié-Salpêtrière (APHP), Paris, France
| | - Christian Spaulding
- Paris Descartes University, Paris, France; INSERM U970 (team 4), Parisian Cardiovascular Research Center, Paris Descartes University, Paris, France; Cardiology Department, Cochin University Hospital (APHP), Paris, France
| | - Florence Barat
- Clinical Trial Unit, Central Pharmacy, APHP, Paris, France
| | - Myriam Ben Boutieb
- Biostatistics and Epidemiology Unit, Hôtel-Dieu Hospital (APHP, Paris, France
| | - Joël Coste
- Paris Descartes University, Paris, France; Biostatistics and Epidemiology Unit, Hôtel-Dieu Hospital (APHP, Paris, France
| | - Jean-Daniel Chiche
- Medical Intensive Care Unit, Cochin Hospital (APHP), Paris, France; Paris Descartes University, Paris, France
| | - Frédéric Pène
- Medical Intensive Care Unit, Cochin Hospital (APHP), Paris, France; Paris Descartes University, Paris, France
| | - Jean-Paul Mira
- Medical Intensive Care Unit, Cochin Hospital (APHP), Paris, France; Paris Descartes University, Paris, France
| | - Jean-Marc Treluyer
- Paris Descartes University, Paris, France; Clinical Research Unit, Paris Centre and Paris Descartes University, Paris, France
| | - Olivier Hermine
- Paris Descartes University, Paris, France; Hematology Department, Necker Hospital (APHP), Imagine institute, INSERM U1123 CNRS erl 8654, Labex des Globules Rouges Grex, Paris, France
| | - Pierre Carli
- Paris Descartes University, Paris, France; SAMU 75, Necker Hospital (AP-HP), Paris, France
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Lapostolle F, van ‘t Hof AW, Hamm CW, Lassen JF, Stibbe O, Ecollan P, Heutz WM, Licour M, Tsatsaris A, Montalescot G. INTERACTION BETWEEN MORPHINE AND TICAGRELOR IN THE ATLANTIC STUDY. J Am Coll Cardiol 2016. [DOI: 10.1016/s0735-1097(16)30546-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Montalescot G, van ’t Hof AW, Bolognese L, Cantor WJ, Cequier A, Chettibi M, Collet JP, Goodman SG, Hammett CJ, Huber K, Janzon M, Lapostolle F, Lassen JF, Licour M, Merkely B, Salhi N, Silvain J, Storey RF, ten Berg JM, Tsatsaris A, Zeymer U, Vicaut E, Hamm CW, Bougherbal R, Bouafia MT, Chettibi M, Nibouche D, Moklati A, Benalia A, Kaid O, Krim M, Hammett C, Garrahy P, Jayasinghe R, Rashford S, Huber K, Neunteufl T, Brussee H, Alber H, Weidinger F, Brunner M, Sipoetz J, Prause G, Baubin M, Sebald D, Cantor W, Vijayaraghavan R, Bata I, Lavoie A, Lassen JF, Ravkilde J, Jensen LO, Christensen AM, Toftegaard M, Köhler D, Montalescot G, Ducrocq G, Danchin N, Henry P, Livarek B, Berthier R, Hovasse T, Garot P, Payot L, Benamer H, Esteve JB, Elhadad S, Teiger E, Bonnet JL, Paganelli F, Cottin Y, Schiele F, Thuaire C, Cayla G, Coste P, Ohlmann P, Cudraz EB, Lantelme P, Perret T, Tron C, De Labriolle A, Aptecar E, Beliard O, Varenne O, El Mahmoud R, Filippi-Codaccioni E, Angoulvant D, Peycher P, Poitrineau O, Tabone X, Ecollan P, Broche C, Lambert Y, Briole N, Beruben A, Porcher N, Auffray JP, Freysz M, Depardieu F, Poubel D, De La Cousaye JE, Bartier JC, Jardel B, Boulanger B, Labourel H, Soulat LC, Lapostolle F, Julie V, Thicoipe M, Capel O, Stibbe O, Carli P, Tazarourte K, Alcouffe F, Aboucaya D, Aubert G, Kierzek G, Cahun-Giraud S, Zeymer U, Hamm C, Dengler T, Prondzinsky R, Biever PM, Schäfer A, Seyfarth M, Lemke B, Werner G, Nef H, Steiger H, Leschke M, Münzel T, Dell Orto MC, Loges C, Schinke M, Koberne F, Reiffen HP, Tiroch K, Wierich D, Kneussel M, Little S, Sauer H, Laufenberg-Feldmann R, Merkely B, Ungi I, Horváth I, Édes I, Mártai I, Bolognese L, Berti S, Chiarella F, Calabria P, Fineschi M, Galvani M, Valgimigli M, Moretti L, Tespili M, Mandó M, Bermano F, Biagioni R, Fabbri A, Ricciardelli A, Petroni MR, Vatteroni UR, Palumbo F, Willems FF, Al Mafragi A, Heestermans TA, Van Eck MJ, Heutz WM, Meppelder H, Jong ARD, Van de Pas H, Fillat ÁC, Tenas MS, Ferrer JM, Peñaranda AS, Ferrer JÁ, Del Blanco BG, Guardiola FM, Ruiz Nodar JM, Romo AÍ, González NV, Nouche RT, De La Llera LD, Hernández García JM, Rivero-Crespo F, Hernández FH, Zamorano Gómez JL, Fárega XJ, Fernández GA, Toboso JL, Carrasco M, Barreiro V, Iglesias Vázquez JA, Montero MDMR, Ortiz FR, Escudero GG, Ingelmo VSB, García AL, Janzon M, Oldgren J, Calais F, Kastberg R, Bergsten PA, Blomberg H, Thörn K, Skoog G, Storey RF, Zaman A, Gerber R, Ryding A, Spence M, Swanson N, Been M, Grosser K, Schofield P, Mackin D, Fell P, Quinn T, Foster T, McManus D, Carson A. Effect of Pre-Hospital Ticagrelor During the First 24 h After Primary Percutaneous Coronary Intervention in Patients With ST-Segment Elevation Myocardial Infarction. JACC Cardiovasc Interv 2016; 9:646-56. [DOI: 10.1016/j.jcin.2015.12.024] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2015] [Revised: 11/30/2015] [Accepted: 12/15/2015] [Indexed: 01/20/2023]
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Montalescot G, Collet JP, Ecollan P, Bolognese L, Ten Berg J, Dudek D, Hamm C, Widimsky P, Tanguay JF, Goldstein P, Brown E, Miller DL, LeNarz L, Vicaut E. Reply: Not All NSTEMIs Are Created Equal. J Am Coll Cardiol 2015; 65:1718-1719. [PMID: 25908088 DOI: 10.1016/j.jacc.2015.01.054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2015] [Accepted: 01/27/2015] [Indexed: 11/18/2022]
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Montalescot G, Collet JP, Ecollan P, Bolognese L, ten Berg J, Dudek D, Hamm C, Widimsky P, Tanguay JF, Goldstein P, Brown E, Miller DL, LeNarz L, Vicaut E. Effect of Prasugrel Pre-Treatment Strategy in Patients Undergoing Percutaneous Coronary Intervention for NSTEMI. J Am Coll Cardiol 2014; 64:2563-2571. [DOI: 10.1016/j.jacc.2014.08.053] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2014] [Revised: 08/04/2014] [Accepted: 08/26/2014] [Indexed: 10/24/2022]
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Montalescot G, van 't Hof AW, Lapostolle F, Silvain J, Lassen JF, Bolognese L, Cantor WJ, Cequier A, Chettibi M, Goodman SG, Hammett CJ, Huber K, Janzon M, Merkely B, Storey RF, Zeymer U, Stibbe O, Ecollan P, Heutz WMJM, Swahn E, Collet JP, Willems FF, Baradat C, Licour M, Tsatsaris A, Vicaut E, Hamm CW. Prehospital ticagrelor in ST-segment elevation myocardial infarction. N Engl J Med 2014; 371:1016-27. [PMID: 25175921 DOI: 10.1056/nejmoa1407024] [Citation(s) in RCA: 435] [Impact Index Per Article: 43.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
BACKGROUND The direct-acting platelet P2Y12 receptor antagonist ticagrelor can reduce the incidence of major adverse cardiovascular events when administered at hospital admission to patients with ST-segment elevation myocardial infarction (STEMI). Whether prehospital administration of ticagrelor can improve coronary reperfusion and the clinical outcome is unknown. METHODS We conducted an international, multicenter, randomized, double-blind study involving 1862 patients with ongoing STEMI of less than 6 hours' duration, comparing prehospital (in the ambulance) versus in-hospital (in the catheterization laboratory) treatment with ticagrelor. The coprimary end points were the proportion of patients who did not have a 70% or greater resolution of ST-segment elevation before percutaneous coronary intervention (PCI) and the proportion of patients who did not have Thrombolysis in Myocardial Infarction flow grade 3 in the infarct-related artery at initial angiography. Secondary end points included the rates of major adverse cardiovascular events and definite stent thrombosis at 30 days. RESULTS The median time from randomization to angiography was 48 minutes, and the median time difference between the two treatment strategies was 31 minutes. The two coprimary end points did not differ significantly between the prehospital and in-hospital groups. The absence of ST-segment elevation resolution of 70% or greater after PCI (a secondary end point) was reported for 42.5% and 47.5% of the patients, respectively. The rates of major adverse cardiovascular events did not differ significantly between the two study groups. The rates of definite stent thrombosis were lower in the prehospital group than in the in-hospital group (0% vs. 0.8% in the first 24 hours; 0.2% vs. 1.2% at 30 days). Rates of major bleeding events were low and virtually identical in the two groups, regardless of the bleeding definition used. CONCLUSIONS Prehospital administration of ticagrelor in patients with acute STEMI appeared to be safe but did not improve pre-PCI coronary reperfusion. (Funded by AstraZeneca; ATLANTIC ClinicalTrials.gov number, NCT01347580.).
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O'Connor S, Kerneis M, Ankri A, Abtan J, Brugier D, Silvain J, Ecollan P, Vicaut E, Collet JP, Montalescot G. More predictable anticoagulation with intravenous enoxaparin than with unfractionated heparin in patients undergoing primary percutaneous coronary intervention: a substudy of the ATOLL trial. Eur Heart J 2013. [DOI: 10.1093/eurheartj/eht308.p2245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Silvain J, Vignalou JB, Beygui F, O'Connor SA, Barthélémy O, Boccara F, Ecollan P, Collet JP, Assayag P, Montalescot G. Impact of transfer time on mortality in acute coronary syndrome with ST-segment elevation treated by angioplasty. Arch Cardiovasc Dis 2012. [PMID: 23199619 DOI: 10.1016/j.acvd.2012.07.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
BACKGROUND In primary percutaneous coronary intervention (pPCI), conflicting data exist on the relative importance of patient presentation time (time from symptom onset (SO) to first medical contact [FMC]) and transfer time (time from FMC to sheath insertion). OBJECTIVES To evaluate the impact of transfer time on mortality in an unselected ST-elevation myocardial infarction (STEMI) population treated with pPCI. METHODS In a well-organized urban network, using mobile intensive care units (MICU) whenever possible, the impact of transfer time on inhospital mortality was evaluated in 703 unselected consecutive STEMI patients transferred for pPCI. RESULTS Our STEMI population included patients with cardiogenic shock (5.3%) and out-of-hospital cardiac arrest (3.7%). Longer transfer times were found to be associated with a stepwise increase in mortality ranging from 2.99% in the first quartile (Q1) up to 8.65% in the fourth quartile (Q4) (P=0.005). This result was noted in patients presenting early (≤2h of SO, 0.96% for Q1 vs. 9.8% for Q4, P=0.006) but not in late presenters (>2h of SO, 7.00% for Q1 vs. 7.8% for Q4, P=0.85). After adjustment for confounding variables such as the severity of patients, the relationship between mortality and transfer time was no longer apparent. CONCLUSIONS In a well-organized urban network dedicated to pPCI, including unselected STEMI patients, transfer time does not appear to be a major contributor to mortality. The relationship of transfer time to mortality seems to be dependent on presentation time and patients' clinical severity.
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Affiliation(s)
- Johanne Silvain
- Institut de Cardiologie, Inserm, Pitié-Salpêtrière Hospital (AP-HP), Université Paris, Paris, France
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Cayla G, Silvain J, Ecollan P, Montalescot G, Collet JP. [Management of ST-elevation myocardial infarction in 2012]. Ann Cardiol Angeiol (Paris) 2012; 61:447-52. [PMID: 23078947 DOI: 10.1016/j.ancard.2012.09.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Improvement of myocardial reperfusion with a greater use of primary percutaneous coronary intervention, adjunctive pharmacological and mechanical therapies have contributed to a spectacular decrease in mortality of patients presenting with ST-elevation myocardial infarction.
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Affiliation(s)
- G Cayla
- Service de cardiologie, université Montpellier 1, CHU de Nîmes, 1, place du Pr-Debrè, 30029 Nîmes cedex, France.
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Ohlmann P, Reydel P, Jacquemin L, Adnet F, Wolf O, Bartier JC, Weiss A, Lapostolle F, Gaultier C, Salengro E, Benamer H, Guyon P, Chevalier B, Catan S, Ecollan P, Chouihed T, Angioi M, Zupan M, Bronner F, Bareiss P, Steg G, Montalescot G, Monassier JP, Morel O. Prehospital abciximab in ST-segment elevation myocardial infarction: results of the randomized, double-blind MISTRAL study. Circ Cardiovasc Interv 2012; 5:69-76, S1. [PMID: 22319064 DOI: 10.1161/circinterventions.111.961425] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The value of prehospital initiation of glycoprotein IIb/IIIa inhibitors remains a controversial issue. We sought to investigate whether in-ambulance initiation of abciximab in patients with ST-segment elevation myocardial infarction (STEMI) improves ST-segment elevation resolution (STR) after primary percutaneous coronary intervention (PCI). METHODS AND RESULTS MISTRAL (Myocardial Infarction with ST-elevation Treated by Primary Percutaneous Intervention Facilitated by Early Reopro Administration in Alsace) is a prospective, randomized, double-blind study. Two hundred and fifty-six patients with acute STEMI were allocated to receive abciximab either in the ambulance (ambulance group, n=127) or in the catheterization laboratory (hospital group, n=129). The primary end point was complete (>70%) STR after PCI. Complete STR was not significantly different between the 2 groups (before PCI, 21.6% versus 15.5%, P=0.28; after PCI, 70.3% versus 65.8%, P=0.49). Thrombolysis In Myocardial Infarction (TIMI) 2 to 3 flow rates before PCI tended to be higher in the ambulance group (46.8% versus 35%, P=0.08) but not after PCI (70.3% versus 65.8%, P=0.49). Slow flow tended to be lower (5.6% versus 13.4%, P=0.07), and distal embolization occurred significantly less often in the ambulance group (8.1% versus 21.1%, P=0.008). One- and 6-month major adverse cardiac event rates were low and similar in both groups. CONCLUSIONS Early ambulance administration of abciximab in STEMI did not improve either STR or TIMI flow rate after PCI. However, it tended to improve TIMI flow pre-PCI and decreased distal embolization during procedure. Larger studies are needed to confirm these results.
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Affiliation(s)
- Patrick Ohlmann
- Pôle d'Activité Médico-Chirurgicale Cardiovasculaire and SAMU 67, Hôpitaux Universitaires de Strasbourg, Université de Strasbourg, France.
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Montalescot G, Zeymer U, Silvain J, Boulanger B, Cohen M, Goldstein P, Ecollan P, Combes X, Huber K, Pollack C, Bénezet JF, Stibbe O, Filippi E, Teiger E, Cayla G, Elhadad S, Adnet F, Chouihed T, Gallula S, Greffet A, Aout M, Collet JP, Vicaut E. Intravenous enoxaparin or unfractionated heparin in primary percutaneous coronary intervention for ST-elevation myocardial infarction: the international randomised open-label ATOLL trial. Lancet 2011; 378:693-703. [PMID: 21856483 DOI: 10.1016/s0140-6736(11)60876-3] [Citation(s) in RCA: 186] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Primary percutaneous coronary intervention (PCI) for ST-elevation myocardial infarction has traditionally been supported by unfractionated heparin, which has never been directly compared with a new anticoagulant using consistent anticoagulation and similar antiplatelet strategies in both groups. We compared traditional heparin treatment with intravenous enoxaparin in primary PCI. METHODS In a randomised open-label trial, patients presenting with ST-elevation myocardial infarction were randomly assigned (1:1) to receive an intravenous bolus of 0·5 mg/kg of enoxaparin or unfractionated heparin before primary PCI. Wherever possible, medical teams travelling in mobile intensive care units (ambulances) selected, randomly assigned (using an interactive voice response system at the central randomisation centre), and treated patients. Patients who had received any anticoagulant before randomisation were excluded. Patients and caregivers were not masked to treatment allocation. The primary endpoint was 30-day incidence of death, complication of myocardial infarction, procedure failure, or major bleeding. The main secondary endpoint was the composite of death, recurrent acute coronary syndrome, or urgent revascularisation. Analysis was by intention to treat. This trial is registered at ClinicalTrials.gov, number NCT00718471. FINDINGS 910 patients were assigned to treatment with enoxaparin (n=450) or unfractionated heparin (n=460). The primary endpoint occurred in 126 (28%) patients after anticoagulation with enoxaparin versus 155 (34%) patients on unfractionated heparin (relative risk [RR] 0·83, 95% CI 0·68-1·01, p=0·06). The incidence of death (enoxaparin, 17 [4%] vs heparin, 29 [6%] patients; p=0·08), complication of myocardial infarction (20 [4%] vs 29 [6%]; p=0·21), procedure failure (100 [26%] vs 109 [28%]; p=0·61), and major bleeding (20 [5%] vs 22 [5%]; p=0·79) did not differ between groups. Enoxaparin resulted in a significantly reduced rate of the main secondary endpoint (30 [7%] vs 52 [11%] patients; RR 0·59, 95% CI 0·38-0·91, p=0·015). Death, complication of myocardial infarction, or major bleeding (46 [10%] vs 69 [15%] patients; p=0·03), death or complication of myocardial infarction (35 [8%] vs 57 [12%]; p=0·02), and death, recurrent myocardial infarction, or urgent revascularisation (23 [5%] vs 39 [8%]; p=0·04) were all reduced with enoxaparin. INTERPRETATION Intravenous enoxaparin compared with unfractionated heparin significantly reduced clinical ischaemic outcomes without differences in bleeding and procedural success. Therefore, enoxaparin provided an improvement in net clinical benefit in patients undergoing primary PCI. FUNDING Direction de la Recherche Clinique, Assistance Publique-Hôpitaux de Paris; Sanofi-Aventis.
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Affiliation(s)
- Gilles Montalescot
- Institut de Cardiologie, CHU Pitié-Salpêtrière (AP-HP), Université Paris 6, Paris, France.
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Silvain J, Bellemain A, Ecollan P, Montalescot G, Collet JP. [Myocardial infarction: Role of new antiplatelet agents]. Presse Med 2011; 40:615-24. [PMID: 21511430 DOI: 10.1016/j.lpm.2011.03.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2011] [Accepted: 03/09/2011] [Indexed: 10/18/2022] Open
Abstract
Thienopyridines have become the cornerstone of treatment of percutaneous coronary intervention although no survival benefit has ever been shown with clopidogrel despite increasing loading doses. Newly developed P2Y(12) inhibitors are more potent, more predictable and have a faster onset of action than clopidogrel, characteristics that make them particularly attractive for high-risk PCI. Four new P2Y(12) inhibitors have been tested each of them having particular individual properties. Prasugrel is an oral prodrug leading to irreversible blockade of the P2Y(12) receptor and is approved worldwide for ACS PCI. Ticagrelor is a direct-acting and reversible inhibitor of the P2Y(12) receptor with potentially more pleiotropic effects. Cangrelor is an intravenous direct and reversible inhibitor of the P2Y(12) receptor providing the highest level of inhibition and elinogrel is an intravenous and oral P2Y(12) antagonist with a direct and reversible action. Both prasugrel and ticagrelor, opposed to clopidogrel, have shown that stronger P2Y(12) inhibition led respectively to significant 19 % and 16 % relative risk reduction of a similar primary endpoint combining cardiovascular death, nonfatal myocardial infarction, or nonfatal stroke. Both drugs showed a significant 0.6 % absolute excess of TIMI major bleeding not related to CABG surgery. The effect of these new compounds is prompt, predictable and powerful as compared to clopidogrel. Their net benefit is particularly marked in PCI for STEMI patients, in which there is no significant increase in major bleeding when compared with clopidogrel. However, because in clinical trials patients perceived to be at higher risk for bleeding usually are excluded, the risk of major and even fatal bleeding might even be higher in a "real-world" setting i.e. in the elderly patient with comorbidities.
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Affiliation(s)
- Johanne Silvain
- Université Paris 6, institut de cardiologie, Inserm CMR937, Pitié-Salpêtrière hospital (AP-HP), Paris, France
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Beygui F, Vicaut E, Ecollan P, Machecourt J, Van Belle E, Zannad F, Montalescot G. Rationale for an early aldosterone blockade in acute myocardial infarction and design of the ALBATROSS trial. Am Heart J 2010; 160:642-8. [PMID: 20934557 DOI: 10.1016/j.ahj.2010.06.049] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2010] [Accepted: 06/28/2010] [Indexed: 11/19/2022]
Abstract
BACKGROUND Aldosterone is at its highest levels at presentation for acute myocardial infarction (AMI). High aldosterone levels are predictive of poor outcome regardless of heart failure. Angiotensin-converting enzyme inhibitors have delayed partial and temporary effects on aldosterone levels. We hypothesize that aldosterone receptor blockade, early after AMI onset on top of standard therapy, may improve clinical outcome. STUDY DESIGN ALBATROSS is a nationwide, multicenter, open-labeled, randomized trial designed to assess the superiority of aldosterone blockade by a 200-mg intravenous bolus of potassium canrenoate followed by a daily 25-mg dose of spirinolactone for 6 months, on top of standard therapy compared to standard therapy alone among 1,600 patients admitted for ST-segment elevation or high risk non-ST-segment elevation acute AMI -TIMI score ≥3-within 72 hours after symptom onset regardless of heart failure and treatment strategy. The primary efficacy end point of the study is the 6-month rate of the composite of death, resuscitated cardiac arrest, significant ventricular arrhythmia, class IA American College of Cardiology/American Heart Association/European Society of Cardiology indication for implantable cardioverter device, and new or worsening heart failure. Secondary end points include each of the components of the primary end point, different combinations of such components, the primary end point assessed at hospital discharge and 30-day follow-up, and rates of acute renal failure. Safety end points include rates of hyperkalemia and premature drug discontinuation. CONCLUSIONS ALBATROSS will assess the cardiovascular benefit of a low-cost aldosterone receptor blocker on top of standard therapy in all-coming AMI patients.
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Affiliation(s)
- Farzin Beygui
- Institut de Cardiologie and INSERM U937, Centre Hospitalier Universitaire Pitié-Salpêtrière, Paris, France
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Montalescot G, Ellis SG, de Belder MA, Janssens L, Katz O, Pluta W, Ecollan P, Tendera M, van Boven AJ, Widimsky P, Andersen HR, Betriu A, Armstrong P, Brodie BR, Herrmann HC, Neumann FJ, Effron MB, Lu J, Barnathan ES, Topol EJ. Enoxaparin in Primary and Facilitated Percutaneous Coronary Intervention. JACC Cardiovasc Interv 2010; 3:203-12. [DOI: 10.1016/j.jcin.2009.11.012] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2009] [Revised: 10/19/2009] [Accepted: 11/13/2009] [Indexed: 02/06/2023]
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Silvain J, Vignalou JB, Bellemain-Appaix A, Landivier A, Barthelemy O, Beygui F, Choussat R, Ecollan P, Collet JP, Montalescot G. 020 Transfer Time is not a major determinant of in-hospital mortality in Primary PCI when performed in a well organized urban network. Archives of Cardiovascular Diseases Supplements 2010. [DOI: 10.1016/s1878-6480(10)70022-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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El Khebir M, Fougeras O, Le Gall C, Santin A, Perrier C, Sureau C, Miranda J, Ecollan P, Bagou G, Trinh-Duc A, Traxer O. Actualisation 2008 de la 8e Conférence de consensus de la Société francophone d’urgences médicales de 1999. Prise en charge des coliques néphrétiques de l’adulte dans les services d’accueil et d’urgences. Prog Urol 2009; 19:462-73. [DOI: 10.1016/j.purol.2009.03.005] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2009] [Accepted: 03/17/2009] [Indexed: 11/15/2022]
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Gueugniaud PY, David JS, Chanzy E, Hubert H, Dubien PY, Mauriaucourt P, Bragança C, Billères X, Clotteau-Lambert MP, Fuster P, Thiercelin D, Debaty G, Ricard-Hibon A, Roux P, Espesson C, Querellou E, Ducros L, Ecollan P, Halbout L, Savary D, Guillaumée F, Maupoint R, Capelle P, Bracq C, Dreyfus P, Nouguier P, Gache A, Meurisse C, Boulanger B, Lae C, Metzger J, Raphael V, Beruben A, Wenzel V, Guinhouya C, Vilhelm C, Marret E. Vasopressin and epinephrine vs. epinephrine alone in cardiopulmonary resuscitation. N Engl J Med 2008; 359:21-30. [PMID: 18596271 DOI: 10.1056/nejmoa0706873] [Citation(s) in RCA: 222] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND During the administration of advanced cardiac life support for resuscitation from cardiac arrest, a combination of vasopressin and epinephrine may be more effective than epinephrine or vasopressin alone, but evidence is insufficient to make clinical recommendations. METHODS In a multicenter study, we randomly assigned adults with out-of-hospital cardiac arrest to receive successive injections of either 1 mg of epinephrine and 40 IU of vasopressin or 1 mg of epinephrine and saline placebo, followed by administration of the same combination of study drugs if spontaneous circulation was not restored and subsequently by additional epinephrine if needed. The primary end point was survival to hospital admission; the secondary end points were return of spontaneous circulation, survival to hospital discharge, good neurologic recovery, and 1-year survival. RESULTS A total of 1442 patients were assigned to receive a combination of epinephrine and vasopressin, and 1452 to receive epinephrine alone. The treatment groups had similar baseline characteristics except that there were more men in the group receiving combination therapy than in the group receiving epinephrine alone (P=0.03). There were no significant differences between the combination-therapy and the epinephrine-only groups in survival to hospital admission (20.7% vs. 21.3%; relative risk of death, 1.01; 95% confidence interval [CI], 0.97 to 1.05), return of spontaneous circulation (28.6% vs. 29.5%; relative risk, 1.01; 95% CI, 0.97 to 1.06), survival to hospital discharge (1.7% vs. 2.3%; relative risk, 1.01; 95% CI, 1.00 to 1.02), 1-year survival (1.3% vs. 2.1%; relative risk, 1.01; 95% CI, 1.00 to 1.02), or good neurologic recovery at hospital discharge (37.5% vs. 51.5%; relative risk, 1.29; 95% CI, 0.81 to 2.06). CONCLUSIONS As compared with epinephrine alone, the combination of vasopressin and epinephrine during advanced cardiac life support for out-of-hospital cardiac arrest does not improve outcome. (ClinicalTrials.gov number, NCT00127907.)
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Affiliation(s)
- Pierre-Yves Gueugniaud
- Service d'Aide Médicale Urgente 69, Hospices Civils de Lyon, University of Lyon 1, Lyon, France.
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Ecollan P, Collet JP, Boon G, Tanguy ML, Fievet ML, Haas R, Bertho N, Siami S, Hubert JC, Coriat P, Montalescot G. Pre-hospital detection of acute myocardial infarction with ultra-rapid human fatty acid-binding protein (H-FABP) immunoassay. Int J Cardiol 2006; 119:349-54. [PMID: 17097752 DOI: 10.1016/j.ijcard.2006.09.003] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2006] [Revised: 09/08/2006] [Accepted: 09/13/2006] [Indexed: 11/17/2022]
Abstract
AIMS To evaluate the diagnostic performance of a portable semi-quantitative whole blood immunoassay measuring soluble human fatty acid-binding protein [H-FABP] (CardioDetect) for the pre-hospital detection of myocardial infarction (MI). METHODS AND RESULTS We enrolled prospectively 108 consecutive patients with acute ischemic type chest pain in whom the first medical care was delivered by a mobile intensive care unit (MICU). CTnI, myoglobin, CK-MB and CardioDetect were first assessed in the MICU before hospital admission using point-of-care assays and then cTnI was serially measured during the hospital stay. MI was defined as a positive cTnI in any sample over the first 24 h. The vast majority of the patients (77/108) were admitted <3 h of symptoms onset. Pre-hospital cTnI sample was normal in 96 patients (88.9%) of whom 43 had subsequent cTnI elevation. A positive H-FABP using the CardioDetect assay had a significantly better sensitivity than cTnI, myoglobin and CK-MB (87.3% vs 21.8%, 64.2% and 41.5%, respectively) to identify MI. The significant better sensitivity of the CardioDetect assay was also observed among patients who presented <3 h of symptom onset. The specificity of the CardioDetect assay was significantly better than that of myoglobin, irrespective of the time delay from symptom onset to measurement. In patients with normal pre-hospital cTnI and no ST-elevation (n=63), assessment based only on a positive H-FABP had 83.3% sensitivity, 93.3% specificity for the diagnosis of an evolving MI. CONCLUSION Early assessment of H-FABP in patients presenting with chest pain improves the diagnosis of ongoing MI.
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Arhan A, Ecollan P, Madonna-Py B, Kergueno J, Bennaceur M, Josse MO, Montalescot G, Riou B. Assessment of early administration of abciximab in acute ST-segment elevation myocardial infarction in the emergency room. Presse Med 2006; 35:45-50. [PMID: 16462663 DOI: 10.1016/s0755-4982(06)74518-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
Abstract
OBJECTIVE Abciximab, a platelet glycoprotein IIb/IIIa inhibitor, administered in conjunction with primary coronary stenting, improves the outcome of acute myocardial infarction, and the earlier it is administered, the greater the improvement. We sought to assess the feasibility of early administration of abciximab in the emergency room (ER) before primary coronary stenting and compare our results with those of a group of patients treated in the prehospital (ambulance) phase. METHODS Data and outcome of patients with acute ST-segment elevation myocardial infarction who received abciximab (0.25 mg x kg(-1) then 0.125 mg x kg(-1) x h(-1)) in the ER before primary coronary stenting were compared with those of patients who received abciximab in the prehospital phase. RESULTS Characteristics of the group treated in the ER did not differ significantly from those of patients treated before arrival at the hospital, except for prevalence of diabetes (22 versus 5%, p<0.05) and administration of analgesic to control chest pain (22 versus 65%, p<0.05). Nor did the median time between onset of pain and abciximab administration differ significantly different (120 versus 160 min, NS). In contrast, the median delay between the beginning of abciximab administration and insertion of the cardiac catheter was significantly shorter in the ER group (35 versus 55 min, p<0.05). There were no significant differences between groups in TIMI flow grade before or after revascularization, specific revascularization performed, or outcome. CONCLUSION Our study provides some evidence that early administration of abciximab in the ER is safe, feasible, and justified by the delay required for coronary revascularization.
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Affiliation(s)
- Amandine Arhan
- Department of Emergency Medicine and Surgery, Centre Hospitalier Universitaire Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Université Pierre et Marie Curie
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Ecollan P, Siami S, Boon G, Fievet ML, Collet JP, Haas R, Montalescot G. [Value of biochemistry performed in pre-hospital cardiology]. Arch Mal Coeur Vaiss 2005; 98:1111-7. [PMID: 16379107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
Abstract
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.
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Affiliation(s)
- P Ecollan
- Département d'anesthésie, SMUR, DAR.
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Collet JP, Dumaine R, Ecollan P, Beygui F, Choussat R, Boon G, Payot L, Montalescot G. [Antithrombotics in pre-hospital phase of acute coronary syndromes]. Arch Mal Coeur Vaiss 2005; 98:1118-22. [PMID: 16379108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
Abstract
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.
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Affiliation(s)
- J P Collet
- Départment de Cardiogie, Institut de Cardiologie, Bureau.
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Montalescot G, Barragan P, Wittenberg O, Ecollan P, Elhadad S, Villain P, Boulenc JM, Morice MC, Maillard L, Pansiéri M, Choussat R, Pinton P. Platelet glycoprotein IIb/IIIa inhibition with coronary stenting for acute myocardial infarction. N Engl J Med 2001; 344:1895-903. [PMID: 11419426 DOI: 10.1056/nejm200106213442503] [Citation(s) in RCA: 872] [Impact Index Per Article: 37.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND When administered in conjunction with primary coronary stenting for the treatment of acute myocardial infarction, a platelet glycoprotein IIb/IIIa inhibitor may provide additional clinical benefit, but data on this combination therapy are limited. METHODS We randomly assigned 300 patients with acute myocardial infarction in a double-blind fashion either to abciximab plus stenting (149 patients) or placebo plus stenting (151 patients) before they underwent coronary angiography. Clinical outcomes were evaluated 30 days and 6 months after the procedure. The angiographic patency of the infarct-related vessel and the left ventricular ejection fraction were evaluated at 24 hours and 6 months. RESULTS At 30 days, the primary end point--a composite of death, reinfarction, or urgent revascularization of the target vessel--had occurred in 6.0 percent of the patients in the abciximab group, as compared with 14.6 percent of those in the placebo group (P=0.01); at 6 months, the corresponding figures were 7.4 percent and 15.9 percent (P=0.02). The better clinical outcomes in the abciximab group were related to the greater frequency of grade 3 coronary flow (according to the classification of the Thrombolysis in Myocardial Infarction trial) in this group than in the placebo group before the procedure (16.8 percent vs. 5.4 percent, P=0.01), immediately afterward (95.1 percent vs. 86.7 percent, P=0.04), and six months afterward (94.3 percent vs. 82.8 percent, P=0.04). One major bleeding event occurred in the abciximab group (0.7 percent); none occurred in the placebo group. CONCLUSIONS As compared with placebo, early administration of abciximab in patients with acute myocardial infarction improves coronary patency before stenting, the success rate of the stenting procedure, the rate of coronary patency at six months, left ventricular function, and clinical outcomes.
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Affiliation(s)
- G Montalescot
- Division of Cardiology, Pitié-Salpêtrière Hospital, Paris, France.
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Plaisance P, Lurie KG, Vicaut E, Adnet F, Petit JL, Epain D, Ecollan P, Gruat R, Cavagna P, Biens J, Payen D. A comparison of standard cardiopulmonary resuscitation and active compression-decompression resuscitation for out-of-hospital cardiac arrest. French Active Compression-Decompression Cardiopulmonary Resuscitation Study Group. N Engl J Med 1999; 341:569-75. [PMID: 10451462 DOI: 10.1056/nejm199908193410804] [Citation(s) in RCA: 117] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND We previously observed that short-term survival after out-of-hospital cardiac arrest was greater with active compression-decompression cardiopulmonary resuscitation (CPR) than with standard CPR. In the current study, we assessed the effects of the active compression-decompression method on one-year survival. METHODS Patients who had cardiac arrest in the Paris metropolitan area or in Thionville, France, more than 80 percent of whom had asystole, were assigned to receive either standard CPR (377 patients) or active compression-decompression CPR (373 patients) according to whether their arrest occurred on an even or odd day of the month, respectively. The primary end point was survival at one year. The rate of survival to hospital discharge without neurologic impairment and the neurologic outcome were secondary end points. RESULTS Both the rate of hospital discharge without neurologic impairment (6 percent vs. 2 percent, P=0.01) and the one-year survival rate (5 percent vs. 2 percent, P=0.03) were significantly higher among patients who received active compression-decompression CPR than among those who received standard CPR. All patients who survived to one year had cardiac arrests that were witnessed. Nine of 17 one-year survivors in the active compression-decompression group and 2 of 7 in the standard group, respectively, initially had asystole or pulseless electrical activity. In 12 of the 17 survivors who had received active compression-decompression CPR, neurologic status returned to base line, as compared with 3 of 7 survivors who had received standard CPR (P=0.34). CONCLUSIONS Active compression-decompression CPR performed during advanced life support significantly improved long-term survival rates among patients who had cardiac arrest outside the hospital.
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Affiliation(s)
- P Plaisance
- Department of Anesthesiology and Critical Care, Lariboisière University Hospital, Paris, France.
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Levy A, Davido A, Ecollan P, Perez T, Sembach N, Leplat P. [Stunned myocardium or hibernating myocardium? Apropos of a case]. Rev Med Interne 1996; 17:61-5. [PMID: 8677386 DOI: 10.1016/0248-8663(96)88397-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
The authors relate a case report of unstable angina pectoris accompanied by a well-documented stunned myocardium phenomenon. Stunned and hibernating myocardium resulting from an acute or chronic coronary ischaemia on the myocardium are notions which widely govern revascularisation indications, especially after a myocardial infarction. At present, their detection is based on isotopic methods and stress echocardiography.
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Affiliation(s)
- A Levy
- Service des urgences médicales, CHU Pitié-Salpêtrière, Paris, France
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Mellière D, Becquemin JP, Ecollan P, Fitoussi M. Abdominal aortic aneurysmectomy in a renal transplant patient: protection of the kidney without adjunctive measures. Cardiovasc Surg 1994; 2:522-4. [PMID: 7953462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Abdominal aneurysmectomy in kidney transplant recipients can be successfully performed without adjunctive protective measures if the period of renal ischaemia is short. A technique that attains this goal is described here. An aortic aneurysm (5 cm) was removed 2 years after kidney transplantation to the left external iliac vessel. The right common iliac artery was divided first and anastomosed to the right branch of the bifurcated graft. Aortic anastomosis was then performed; the period of renal ischaemia was only 20 min. Arterial flow was re-established in the right common iliac artery, providing profuse collateral flow to the transplanted kidney through the internal iliac arteries during the time necessary to complete the left common iliac artery anastomosis. This procedure is feasible unless the internal iliac artery is severely stenosed, occluded or terminally anastomosed to the transplanted renal artery. In all other cases, this technique may be the optimal procedure to protect the kidney during elective abdominal aorta aneurysmectomy in renal transplant recipients by reducing the period of ischaemia to that of one anastomosis only.
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Mellière D, Becquemin JP, Benyahia NE, Ecollan P, Fitoussi M. Atherosclerotic disease of the innominate artery: current management and results. J Cardiovasc Surg (Torino) 1992; 33:319-23. [PMID: 1601916] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Arterial repair through a sternotomy has long been considered the procedure of choice for innominate artery atherosclerotic disease. Of 22 patients presenting with 21 occlusive lesions and one aneurysm, 17 patients underwent a bypass procedure, and two, an endarterectomy through a sternotomy, whereas three patients underwent cervical procedures. Their postoperative course was uneventful. Early and late results were satisfactory. We conclude that in patients with innominate artery atherosclerotic disease, the procedure employed depends on both the type of lesion and the clinical status of the patient. In most cases, a bypass graft via a sternotomy is the best option, since endarterectomy is not always possible and risks an aortic tear or dissection. In selected cases, balloon angioplasty performed either percutaneously, combined with cerebral protection by an occlusive balloon in the carotid artery or through a carotid arteriotomy in order to flush out embolic material may be sufficient. A by-pass graft from the right to the left common carotid artery is the best procedure in patients with neurological symptoms when angioplasty seems inappropriate, and when sternotomy is contraindicated for either reasons of poor health or a prior mediastinal operation.
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Affiliation(s)
- D Mellière
- Division of Vascular Surgery, University Paris XII, France
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Mellière D, Ecollan P, Kassab M, Becqemin JP. Adventitial cystic disease of the popliteal artery: treatment by cyst removal. J Vasc Surg 1988; 8:638-42. [PMID: 3184317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Controversy still exists concerning the optimal treatment for adventitial cystic disease of the popliteal artery: complete removal of the cyst without arterectomy or arteriectomy with venous replacement. In the two cases presented here, it was possible to completely excise the cyst and to preserve a solid arterial wall despite the magnitude of lesions documented on preoperative angiograms. Good functional and anatomic outcome has been maintained for 5 and 9 years, respectively. According to the available literature on pathologic data, complete cyst excision without arterial reconstruction is often feasible. Our results, as well as those published by others, suggest that short- and long-term outcome is better after complete cyst removal without than that with arterial reconstruction. As most patients are generally young adults, cystic excision should be preferred to venous bypass whenever feasible and whenever the remaining arterial wall seems to be healthy and solid.
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Affiliation(s)
- D Mellière
- Department of Vascular Surgery, Henri Mondor Hospital, Paris XII University, France
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