Conflits d intérêt Astra-Zeneca, BMS, MSD, Novartis, Pfizer, Daiichi-Sankyo, Servier, CRAM, AFSSAPS, ARH Région de Bourgogne Clos Vougeot Agrément FMC N 100 437
Popul. millions Area km2 Density inha/km2 NORD 2,5 5 743 447 Essonne 1,2 1 804 668 Hte Garonne 1,2 6 309 193 Hte Savoie 0,7 4 388 163 Côte d Or 0,5 8 763 60 Nord Essonne Côte-d Or Haute-Savoie Haute-Garonne # 6
Demographic characteristics 200 patients analysed Côte- d Or : 29 Haute- Garonne : 39 Nord : 57 Haute- Savoie : 37 Essonne : 38 Almost 3/4 of males : 72,5 % male
Demographic characteris<cs Mean age : 63,3 yrs with regional differences : 69,4 yrs in Côte- d Or 60,0 yrs in Essonne More than half of pa<ents re<red (54 %), with regional differences 74,1 % in Côte- d Or 40,5 % in Essonne
Risk factors and medical history Hypertension : 43,5 % Diabetes : 21,4 % AcYve smoking : 44,9 % Mean weight : 77 kg BMI 30 : 20,8 % CAD known prior to admission : 19,7 %
First aid Chest pain reported in 93,9 % of cases In 3/4 of cases (71,1 %), chest pain triggers a phone call Emergency number 15 : only in 49 % of cases Emergency ambulance (SAMU/SMUR) is the 1st medical contact in less than 50 % of cases
Revascularisa<on modes Popula<on Age Female (%) Occupa<on (%) Employed Unemployed ReYred Fibrinolysis Primary PCI no reperfusion p 22 % 64 % 14 % < 0,001 63 ± 13 23 % 62 ± 13 24 % 70 ± 12 50 % < 0,01 < 0,02 44 5,1 51,3 41 8,1 50,5 22 4,3 73,9 Pa<ents without reperfusion : older Half are female ¼ are employed 0,32
14 22 Primary PCI Thrombolysis No reperfusion64 France Widimsky P et al, Eur Heart J 2010; 31:943-57.
Pa<ents referred directly to an interven<onal cardiology unit sympto m onset 1er call 33 min FMC 20 min Admission 54 min P PCI 43 min 97 min Preferred strategy is direct hospitalisation to cath-lab 64 % as an average 70,2 % if patient referred by medical ambulance
Pa<ents referred to peripheral centres Symptom onset Admission to the cath lab FMC 163 min 204 min Mean delay was more than double 227 min P PCI
% hospital mortality $% Effects of numbers of actors 9,7 # " 4,2 5,5! &'$ % () Nr of actors
Population USIK USIC FAST-MI FAST-MI 1995 2000 2005 2010 2152 2320 3059 3069 patients 373 centres patients 369 centres patients 223 centres patients 213 centres 1536 STEMI 1844 STEMI 1611 STEMI 1716 STEMI
FAST-MI 2010 213 centres Inclusion from October 2010 4169 patients included 3079 patients included during the first month
Proportion of STEMI patients from 1995 to 2010 Generalised use of troponin measurement
Admission diagnosis: STEMI vs NSTEMI
First place of arrival STEMI 38+11.5% call SAMU first NSTEMI 21% call their GP first 19% go to ER 29+8% call SAMU first 27% call their GP first 19% go to ER
Increased % of younger women
Time to first call in STEMI patients 2000 2005 2010 Median 138 90 74 25 th ; 75 th percentiles 60; 480 30; 287 30; 240 % of patients calling 60 min from onset
Use of the SAMU/firebrigade in STEMI Use of the SAMU/ FB in patients with STEMI 2005 2010
Reperfusion therapy in STEMI
STEMI: early mortality according to use and type of reperfusion therapy 2.1 2.6-48 % - 74 % - 70 %
30-day mortality: STEMI & NSTEMI 5?
Mortality according to timing of PCI after thrombolysis FAST-MI 2005 All patients with PCI after lysis Systematic pharmaco-invasive Rescue or symptom-driven PCI No PCI PCI 128 minutes PCI 129-220 minutes PCI > 220 minutes
Genetic determinants of clopidogrel response and clinical events in FAST-MI 2005 FAST- MI registry 2,208 patients with AMI, followed for one year Number of CYP2C19 loss- of- function alleles Simon et al. NEJM 2009
Early prescription of statins is associated with lower risk of developing acute AF % of patients developing AF Danchin et al. Heart 2010
LMWH vs UFH in elderly patients Survival in propensity score-matched cohorts Any blood Puymirat et al. Int J Cardiol 2012 transfusion Adjusted OR [95% CI] Major bleeding 0.41 [0.20-0.83] 0.49 [0.28-0.85]
Standard vs loading dose of clopidogrel in elderly patients: FAST-MI 2005 One-year event-free survival Adjusted HR (95%CI): 0.92 (0.68-1.25) Bleeding or Puymirat et al. transfusion Am J Cardiol 2011 Adjusted OR [95% CI] In-hospital death 0.91 [0.50-1.68] 1.03 [0.49-2.17]
Conclusion Periodical surveys are a unique tool to document the evolution of management and outcomes in patients admitted with AMI. Both the organisation of care and acute management have considerably evolved in the past 15 years.
Conclusion Early mortality has impressively decreased, both for STEMI and NSTEMI patients. The improved outcome in AMI patients is not related to one single therapeutic measure, but rather results from an improvement in the overall process of care. There are many lessons to be learned from such surveys.