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Biomedical subjects

P G Steg

Publications and source records attributed to P G Steg.

At least 19 recordsLinked to original sources
PubMed2006

Bypassing the emergency room reduces delays and mortality in ST elevation myocardial infarction: the USIC 2000 registry.

OBJECTIVE: To study the impact on outcomes of direct admission versus emergency room (ER) admission in patients with ST-segment elevation myocardial infarction (STEMI) DESIGN: Nationwide observational registry of STEMI patients SETTING: 369 intensive care units in France. INTERVENTIONS: Patients were categorised on the basis of the initial management pathway (direct transfer to the coronary care unit or catheterisation laboratory versus transfer via the ER). MAIN OUTCOME MEASURES: Delays between symptom onset, admission and reperfusion therapy. Mortality at five days and one year. RESULTS: Of 1204 patients enrolled, 66.9% were admitted direct and 33.1% via the ER. Bypassing the ER was associated with more frequent use of reperfusion (61.7% v 53.1%; p = 0.001) and shorter delays between symptom onset and admission (244 (interquartile range 158) v 292 (172) min; p < 0.001), thrombolysis (204 (150) v 258 (240) min; p < 0.01), hospital thrombolysis (228 (156) v 256 (227) min, p = 0.22), and primary percutaneous coronary intervention (294 (246) v 402 (312) min; p < 0.005). Five day mortality rates were lower in patients who bypassed the ER (4.9% v 8.6%; p = 0.01), regardless of the use and type of reperfusion therapy. After adjusting for the simplified Thrombolysis in Myocardial Infarction (TIMI) risk score, admission via the ER was an independent predictor of five day mortality (odds ratio 1.67, 95% confidence interval 1.01 to 2.75). CONCLUSIONS: In this observational analysis, bypassing the ER was associated with more frequent and earlier use of reperfusion therapy, and with an apparent survival benefit compared with admission via the ER.

Aged↗
PubMed2006

Intervention in acute coronary syndromes: do patients undergo intervention on the basis of their risk characteristics? The Global Registry of Acute Coronary Events (GRACE).

OBJECTIVE: To determine whether revascularisation is more likely to be performed in higher-risk patients and whether the findings are influenced by hospitals adopting more or less aggressive revascularisation strategies. METHODS: GRACE (Global Registry of Acute Coronary Events) is a multinational, observational cohort study. This study involved 24,189 patients enrolled at 73 hospitals with on-site angiographic facilities. RESULTS: Overall, 32.5% of patients with a non-ST elevation acute coronary syndrome (ACS) underwent percutaneous coronary intervention (PCI; 53.7% in ST segment elevation myocardial infarction (STEMI)) and 7.2% underwent coronary artery bypass grafting (CABG; 4.0% in STEMI). The cumulative rate of in-hospital death rose correspondingly with the GRACE risk score (variables: age, Killip class, systolic blood pressure, ST segment deviation, cardiac arrest at admission, serum creatinine, raised cardiac markers, heart rate), from 1.2% in low-risk to 3.3% in medium-risk and 13.0% in high-risk patients (c statistic = 0.83). PCI procedures were more likely to be performed in low- (40% non-STEMI, 60% STEMI) than medium- (35%, 54%) or high-risk patients (25%, 41%). No such gradient was apparent for patients undergoing CABG. These findings were seen in STEMI and non-ST elevation ACS, in all geographical regions and irrespective of whether hospitals adopted low (4.2-33.7%, n = 7210 observations), medium (35.7-51.4%, n = 7913 observations) or high rates (52.6-77.0%, n = 8942 observations) of intervention. CONCLUSIONS: A risk-averse strategy to angiography appears to be widely adopted. Proceeding to PCI relates to referral practice and angiographic findings rather than the patient's risk status. Systematic and accurate risk stratification may allow higher-risk patients to be selected for revascularisation procedures, in contrast to current international practice.

Aged↗
PubMed2006

Are there good and bad responders to prehospital thrombolysis in the acute phase of myocardial infarction? OPTIMAL study rationale.

The effectiveness of thrombolytics has been clearly demonstrated in more than half the cases in the large cohorts of patients selected for trials during the acute phase of myocardial infarction. At individual level, thrombolysis will clinically either succeed or fail so, for the medical team managing the patient, choice of treatment may be likened to a gamble which in the best of cases (most often) leads to an uncomplicated success and, in the worst of cases, failure worsened by a severe complication. OPTIMAL is a multidisciplinary and multicentre, prospective cohort study associating mobile medical teams and interventional cardiology units to test the hypothesis that the outcome of prehospital thrombolysis does not depend on chance alone but also varies according to demographic, etiological, clinical and logistic factors involved in the occurrence and management of myocardial infarction. The primary objective of this French study, conducted over one year on more than 800 subjects, is to identify the predictors of the results of prehospital thrombolysis from a very early angiographic evaluation. The results for this cohort may be useful for setting up appropriate management strategies for acute myocardial infarction, from the prehospital phase (thrombolysis or not) up to in-hospital orientation of the patients (angiography room or Intensive Care Unit) and to determine the most judicious time for coronary angiography. OPTIMAL is to date the largest prospective serie of prehospital thrombolysis evaluated by an early angiographic control.

Coronary Angiography↗
PubMed2005

Impact of chronic oral anticoagulation on management and outcomes of patients with acute myocardial infarction: data from the RICO survey.

OBJECTIVE: To determine the prevalence of chronic oral anticoagulant drug treatment (COA) among patients with acute myocardial infarction (AMI) and its impact on management and outcome. METHODS: All patients with ST segment elevation AMI on the RICO (a French regional survey for AMI) database were included in this analysis. COA was defined as continuous use >or= 48 hours before AMI. RESULTS: Among the 2112 patients with ST elevation myocardial infarction (STEMI), 93 (4%) patients were receiving COA. These patients were older and more likely to have a history of hypertension, diabetes and prior myocardial infarction than patients without COA. In addition, fewer patients who received COA underwent reperfusion therapy or received an antiplatelet agent (aspirin/thienopyridines). Moreover, patients receiving COA experienced a higher incidence of in-hospital major adverse events (death, recurrent myocardial infarction or major bleeding, p = 0.005). Multivariate analysis showed that only ejection fraction, current smoking and multiple vessel disease, but not COA, were independent predictive factors for major adverse events. In contrast, COA was an independent predictive factor for heart failure when adjusted for age, diabetes, creatinine clearance, reperfusion, heparin and glycoprotein IIb/IIIa inhibitors (odds ratio 2.06, CI 95% 1.23 to 3.43, p = 0.005). CONCLUSION: In this population based registry, patients with STEMI with prior use of COA constituted a fairly large group (4%) with an overall higher baseline risk profile than that of patients without COA. Fewer in the COA group received reperfusion therapy or aggressive antithrombotic treatment and they experienced more adverse in-hospital outcomes. Thus, further studies are warranted to develop specific management strategies for this high risk group.

Administration, Oral↗
PubMed2004

[Acute coronary syndromes and pheochromocytoma].

Pheochromocytoma can induce a adrenergic cardiomyopathy. This one occurs sometimes clinical, biological or and electrocardiographic signs of an acute coronary syndrome. We report two cases of rudimentary necrosis due to a pheochromocytoma: the first one after tumorectomy, the second one has revealed the disease in a patient who was suffering from high blood pressure for many years. The coronarography was in each case normal.

Acute Disease↗
PubMed2004

[Angioplasty of saphenous vein grafts in the acute phase of myocardial infarction. Short and mid-term results].

The impact of the progress of interventional cardiology on the improved prognosis of myocardial infarction due to occlusion of a saphenous vein bypass graft is not well known. The aim of this study was to report the modalities and results at short and medium term of revascularisation by angioplasty of venous grafts in the acute phase of myocardial infarction. Out of a total of 870 consecutive patients treated by angioplasty in the first 6 hours of myocardial infarction with persistent ST elevation between 1990 and 2002, 16 (2%) had acute occlusion of a saphenous vein graft. Twelve of the 16 patients had previous myocardial infarction; perfusion was obtained in 7 patients. The attempt failed in 9 patients because of "no-reflow" (n=5), the extensive nature of the thrombosis (n=2) and technical failure (n=2). Three patients died in hospital, all after failed angioplasty. At 6 months, of the 13 survivors of the hospital period, 2 had been readmitted for a revascularisation procedure. At 2 years, 3 patients had died, 2 were readmitted for recurrent myocardial infarction and 8 patients remained free of a major cardiovascular event. Reperfusion by angioplasty of an occluded saphenous vein graft in the acute phase of myocardial infarction remains imperfect and the prognosis at short and medium term is poor.

Aged↗
PubMed2003

[FACT: French national registry of acute coronary syndromes. Specific study of French general hospital centers].

UNLABELLED: The FACT registry is currently the French registry including the greatest number of patients with acute coronary syndromes. PURPOSE: The study presents epidemiologic data, modalities and delays for medical admission. METHOD: Three thousand nine hundred and two patients were included in FACT by 362 French centers of cardiology between 06/01/2003 and 03/02/2003. One thousand eight hundred and ten patients, who had been placed in the cardiology departments of French general hospitals, were isolated from this registry. The French general hospitals represented 50.8% of the 362 centers. In order to clarify the study, these patients were divided into three groups: group A: patients without ST segment elevation but with suggestive ECG modifications; group B: patients with ST segment elevation; group C: all other patients. The results were mainly studied for groups A and B and compared. These results were also compared to those of the FACT registry and of other registries. RESULTS: The results show that the average delay for admission is 2.9 h after a first delay between the pain and the help of 6.7 h. The first intervening party is a general practitioner (36.4%) then the SAMU (31.6%) and finally the emergency departments (18.7%). 16.6% of the patients from group B undergo pre-hospital thrombolysis. The recommendations of the European Society of Cardiology are widely applied except for the most recent of them since only 27.6% of the patients from group A having a TIMI score > or = 5 receive an anti-GIIB IIIA treatment. The reasons of the non-prescription of the recommended classes are mostly linked to contra-indication and intolerance. The strategy of coronary reopening mainly depends on the presence or the absence in the department of an available medical equipment for angioplasty. If there is one, the percentage of primary angioplasty reaches 54.2% and the percentage of thrombolysis 7.9%. On the opposite, there is 8.3% of angioplasty and 54.2% of thrombolysis for the unequipped centers. The global mortality reaches 5.8% but is inversely proportional to the level of equipment of the departments: 5.9% for the departments with angioplasty, 11% for the departments with coronarography but without angioplasty and 13.8% for the departments without any interventional equipment. Nevertheless, the age of the patients is different and this influences the results: we notice that the less equipped the department is, the older the patients are. CONCLUSION: The FACT registry and the data from the general hospitals give the opportunity to think about the possibilities to improve the delays of call to the first intervening party (more particularly to the SAMU) but it also allows us to think about how to better organize the geographical distribution giving access to a medical equipment for angioplasty. All these information will also help the cardiologists to gather around the recommendations by convincing them that the benefit/risk ratio is positive.

Adult↗
PubMed2003

[Measurement of coronary reserve by high-frequency transthoracic Doppler ultrasonography: indications and results].

Coronary flow reserve is the ability of coronary flow to increase above its basal value when the coronary vascular bed is maximally dilated. It is a global parameter of coronary flow, which is early altered in the presence of epicardial coronary artery stenosis or a coronary microcirculation disorder. Until now, clinical use of coronary flow reserve has been hampered by the lack of an easy, reliable and non-invasive method. Recently developed high-frequency transthoracic Doppler echocardiography now allows non-invasive assessment of coronary flow reserve. After an initial learning curve, it is possible to study coronary flow, essentially in the left anterior descending artery. Coronary flow reserve is expressed as the ratio of maximal hyperaemic to basal mean coronary velocity. Maximal hyperaemic flow is obtained with adenosine. Clinical applications of coronary flow reserve are numerous. Coronary flow reserve enables the assessment of hemodynamic relevance of a moderate coronary stenosis. Detection of coronary restenosis is also possible by repeated non-invasive measurement of coronary flow reserve. Moreover, evaluation of the microcirculation is of crucial importance in order to appreciate myocardial reperfusion following successful recanalisation on the infarct-related artery. Transthoracic Doppler echocardiography could allow identification of "no-reflow" by analysis of coronary flow pattern and coronary flow reserve. Furthermore, transthoracic Doppler echocardiography constitutes one of the only available and simple means to evaluate microcirculatory disorders (hypertension, diabetes,...). Finally, the possibility of non-invasive follow-up of arterial bypasses constitutes a major advantage of this technique.

Coronary Stenosis↗
PubMed2003

[Femoral artery hemostasis after coronary angioplasty with moderate dose of heparin].

UNLABELLED: Early retraction of the arterial introducer facilitates patient management after coronary angioplasty. Closure systems permit rapid haemostasis, but are costly and do not avoid all serious vascular complications. Moderate doses of heparin, used often at the moment, could allow immediate retraction of the introducer with rapid and safe haemostasis by manual compression. METHODS: We evaluated prospectively in 350 consecutive patients the safety and efficacy of immediate retraction of the 6F introducer after coronary angioplasty performed by the femoral route with a moderate dose of heparin (70 IU. kg-1). Only procedures during acute infarction or using abciximab electively were excluded. RESULTS: Retraction of the introducer was immediate in 340 patients (97%). The dose of heparin administered was 5300 +/- 800 IU and the compression time was 11 +/- 4 minutes. The activated clotting time at retraction of the introducer was 254 +/- 46 s. Six (1.7%) serious vascular complications (4 significant haematomas and 2 false aneurysms) were noted during the hospital phase. A single patient (0.6%) was transfused and no vascular surgical procedure was necessary. The average duration of stay after angioplasty was 2.6 +/- 2.2 days and 73% of patients left before 48 hours. CONCLUSION: Immediate retraction of the arterial introducer is possible with simple manual compression, after coronary angioplasty performed with a moderate dose of heparin.

Angioplasty↗
PubMed2003

[Changes in reperfusion strategies in the acute phase of myocardial infarction from 1988 to 2001].

The objective of this study was to evaluate the evolution of therapeutic strategies in the course of myocardial infarction. Two successive periods were studied: 1988/96 (700 patients) and 1996/2001 (700 patients). The following parameters were compared: patient characteristics, management methods, and results on the hospital morbidity and mortality. The patient characteristics were little changed, in terms of age and sex, with a drop in the frequency of anterior infarcts during the second period (46 vs 51%, p = 0.0001). The average delay to admission remained stable over both periods, 186 vs 189 min. During the second period, primary angioplasty was favoured (66 versus 44%, p = 0.0001), associated with a wider use of stents (47 against 4%, p = 0.0001) and anti GP IIb/IIIa (24 against 0.5%, p = 0.0001). In the acute phase, TIMI3 reperfusion was obtained in 81% of cases (88/96 period) against 88% during the second period (p = 0.02). The hospital mortality was reduced by 1.2% (8.9 against 7.7%, NS). Without cardiogenic shock, the mortality was comparable between the two groups (5%), whereas it diminished in the small group of patients (5%) in cardiogenic shock, from 76 to 66% (NS). Haemorrhagic complications were reduced, but the rate of symptomatic reocclusion remained stable (2.5%). With multivariate analysis, the independent predictive mortality factors were identical in the two groups: age and cardiogenic shock on admission. Currently, TIMI3 reperfusion is possible in close to 90% of patients in the acute phase of infarction. Our efforts should focus on earlier management, especially for older patients, too often excluded without reason, and for those in cardiogenic shock, which constitutes a therapeutic quest for the future. The theory of angioplasty facilitated by anti GP IIb/IIIa and/or prehospital thrombolysis must be evaluated scientifically with the goal of early and efficient reperfusion for the greatest number of patients.

Aged↗
PubMed2002

A tale of two countries: costs and financial incentives for provisional stenting during percutaneous coronary intervention in France and the United States.

Provisional stenting is associated with longer physician time but the use of fewer stents. This randomized controlled trial in tertiary care in French hospitals compared strategies of systematic and provisional stenting. We estimated the costs and financial incentives associated with each strategy, based on individual data on 12-month resource use drawn from a 251-patient database. Resources were evaluated using French costs; data on costs in the United States were drawn from the literature and interviews with hospital administrators in one center. In France 1-year costs were 8,267+/-528 dollars for provisional stenting and 7,973+/-553 dollars for systematic stenting, compared to 18,715 dollars and 18,632 dollars in the United States. Given the uncertainty of longterm results, the choice between stenting strategies might be guided by financial incentives. In the United States financial incentives favor systematic stenting, while in France public hospitals and physicians are neutral.

Clinical Trial↗
PubMed2002

Management of acute coronary syndromes. Variations in practice and outcome; findings from the Global Registry of Acute Coronary Events (GRACE).

AIMS: Despite advances in the treatment of acute coronary syndromes based on randomized trial data and published guidelines, the extent to which such treatments are applied in practice remains uncertain. Data from clinical trials derive from selected geographical areas and in highly selected populations of patients, and hence may not reflect the overall population. The aim of the study was to investigate variations in hospital management and outcome using unselected data collected in the prospective Global Registry of Acute Coronary Events (GRACE). METHODS AND RESULTS: The 95 hospitals in GRACE were organized into 18 population-based clusters in 14 countries. Information was recorded about patient management and outcome during hospitalization and after discharge. Data on treatments administered were analysed by baseline condition, hospital type, by the presence or absence of a catheterization laboratory, and by geographical region. Of 11543 patients, 44% had an admission diagnosis of unstable angina, 36% presented with myocardial infarction, 9% were admitted to rule out a myocardial infarction, 7% had chest pain and 4% were hospitalized for 'other cardiac' and 'non-cardiac' diagnoses. Of the total GRACE population 38% had a final diagnosis of unstable angina, 30% ST-segment elevation myocardial infarction, 25% non-ST-segment elevation myocardial infarction, and 7% of 'other cardiac' and 'non-cardiac' final diagnoses. The event rates for hospital death or reinfarction were six and 2% for non-ST-segment elevation myocardial infarction, seven and 3% for ST-segment elevation myocardial infarction, and 3% hospital death for unstable angina. The use of aspirin was similar across all hospital types and geographical regions. In contrast, the use of percutaneous coronary intervention and glycoprotein IIb/IIIa inhibitors was higher (P<0.0001) in teaching hospitals and hospitals with catheterization laboratories and was also higher in the United States. At discharge a higher percentage (P<0.0001) of patients received angiotensin-converting enzyme inhibitors in hospitals without catheterization laboratories. The use of statins was lower in non-teaching hospitals and in centres without a catheterization laboratory. CONCLUSIONS: The GRACE study reveals substantial differences in the management of patients based on hospital type and geographical location. Further analyses will determine whether such variations translate into differences in longer term outcomes. GRACE provides a multinational reference for the implementation of therapies of proven efficacy.

Acute Disease↗
PubMed2002

Impact of availability and use of coronary interventions on the prescription of aspirin and lipid lowering treatment after acute coronary syndromes.

BACKGROUND: It has been suggested that patients undergoing acute intervention for coronary syndromes may not receive adequate secondary prevention. OBJECTIVE: To analyse the impact of availability and use of coronary interventions on the prescription of secondary prevention after acute coronary syndromes. DESIGN: Analysis of a prospective multicentre register of patients admitted to hospital for acute coronary syndromes. SETTING: A 1999 pan-European survey in 390 hospitals. PATIENTS: 3092 patients admitted to hospital with acute coronary syndromes (including 777 for ST elevation myocardial infarction within 12 hours of onset). MAIN OUTCOME MEASURES: Rates of prescription of aspirin and lipid lowering agents. RESULTS: Performance of coronary angiography and percutaneous coronary interventions (PCI) during the hospital stay were independent predictors of prescription of aspirin at discharge (odds ratio (OR) 1.29 and 1.89, p = 0.053 and p < 0.0001, respectively). Lipid lowering agents were prescribed more often on discharge in patients admitted to hospitals with catheterisation laboratories than without (for infarction with ST elevation, 45% v 40% (NS); for other acute coronary syndromes, 46% v 36%; p < 0.05). Prescription rates were higher among patients undergoing coronary angiography or PCI than in those treated conservatively (for infarction with ST elevation, 49%, 53%, and 39%, p < 0.05; for other acute coronary syndromes, 50%, 54%, and 34%, p < 0.05). Logistic regression analysis showed that PCI was an independent predictor of prescription of lipid lowering agents at discharge (OR 1.48, p < 0.0002). CONCLUSIONS: Contrary to expectations, invasive procedures for acute coronary syndromes are associated with higher rates of prescription of pharmacological secondary prevention.

Adrenergic beta-Antagonists↗
PubMed2002

[Myocardial revascularization at the acute phase of myocardial infarction in the octogenarian].

Elderly patients are at high risk of complications in acute myocardial infarction (AMI). In this population, myocardial reperfusion at the acute phase improves the prognostic. The mortality rate is above 50% in the absence of reperfusion strategy, and decreases at less than 20% in case of such treatment. The thrombolytic use is limited in those patients, coronary angioplasty is taking an important place in this reperfusion therapy, but is not well evaluated in patients older than 80 years. Prospective registry of patients older than 80 years admitted in Hôpital Bichat for acute myocardial infarction within the first 6 hours (n = 92), between 1990 january to 1999 december. Eight patients (10%) received a thrombolytic therapy. Coronary angiogram was achieved in eighty patients (87%). In 58 (63%) patients a coronary angioplasty was performed. The success rate of the coronary angioplasty was 86%. In-hospital mortality rate was 26% (death in 24 patients), 20% in the absence of cardiogenic shock and 62% when this complication was noted. Two patients (2%) were treated by emergent coronary artery bypass surgery. The results comparison between the periods of 1990 to 95 and 1955 to 99 showed, a real trend of decrease mortality rate (28 to 13% in the absence of cardiogenic shock, p = 0.10), an increase of the proportion of patients treated by angioplasty. These results are more and more encouraging. Coronary reperfusion by primary angioplasty in possible in patients older than 80 years with a low rate of complications. Technical progress such as stents and GpIIb/IIIa inhibitors must be evaluated in this population.

Aged↗
PubMed2001

Differential expression of matrix metalloproteinases after stent implantation and balloon angioplasty in the hypercholesterolemic rabbit.

BACKGROUND: Intimal hyperplasia is the principal mechanism of in-stent restenosis. Matrix metalloproteinases (MMPs) play a key role in intimal growth after balloon angioplasty (BA). Little is known, however, about MMP expression after stent implantation (ST). We investigated whether MMP9 and MMP2 are differentially expressed after ST and BA. METHODS AND RESULTS: Hypercholesterolemic rabbits underwent ST and BA in the right and left iliac arteries, respectively. The expression of MMPs and their inhibitors (TIMPs) was studied at various time points in the injured arteries by use of zymography, reverse transcription-polymerase chain reaction, and immunohistochemistry. MMP2, but not MMP9, was constitutively expressed in uninjured arteries. MMP9 expression was rapidly induced after injury, whereas the increase in MMP2 expression was delayed. At all time points, pro-MMP9 activity and MMP9 mRNA levels were >/=2-fold (ANOVA, P=0.002) and >/=3-fold (P<0.0001) higher after ST than after BA, respectively. Active MMP9 was detected only after ST. Although the increases in MMP2 mRNA levels were of similar magnitudes after ST and BA, pro-MMP2 activity was slightly higher 7 and 30 days after ST, and MMP2 activity was >/=2-fold higher 7 to 60 days after ST (P=0.002). No difference in TIMP expression was observed between stented and balloon-injured arteries. Cellular distributions of MMPs and TIMP1 were similar after ST and BA. Early inflammatory cell recruitment and 30-day intimal growth were more severe after ST. CONCLUSIONS: Stent implantation results in more intense and sustained expression of MMP9 and activation of MMP2 than balloon angioplasty.

Angioplasty, Balloon↗