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Biomedical subjects

P Guéret

Publications and source records attributed to P Guéret.

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

High risk hypertensives: pre-hospital management of acute myocardial infarction--results from the French nationwide registry USIC 2000.

OBJECTIVE: To assess the use of mobile coronary care units (MCU) in hypertensive patients previously treated for cardiovascular diseases in comparison with those with no history of cardiovascular disease and to estimate the influence of the use of MCU on cardiovascular outcome in this population. PATIENTS: We used a nationwide prospective registry of all patients admitted for AMI in French intensive care units in 2000. Patients without history of hypertension or patients admitted with pulmonary oedema or cardiogenic shock were excluded. Men (N = 514) and women (N = 291) were analysed separately. RESULTS: The proportion of patients with history of myocardial infarction, peripheral artery disease and stroke was not significantly higher in subjects who used physician-staffed MCU as compared with patients with no history of myocardial infarction, peripheral artery disease or stroke. In each sex, revascularization (pre hospital fibrinolysis, in hospital fibrinolysis or coronary angioplasty) were more frequent in patients who used MCU. Also, one year cardiovascular mortality was lower in men who used MCU. CONCLUSION: Known high risk hypertensive patients did not use physician-staffed MCU more than subjects free of such condition. Education of hypertensive patients at risk during routine visits is required to increase of the use of physician-staffed MCU in case of symptoms suggestive of AMI.

Aged↗
PubMed2005

Major impact of admission glycaemia on 30 day and one year mortality in non-diabetic patients admitted for myocardial infarction: results from the nationwide French USIC 2000 study.

OBJECTIVE: To analyse the short and long term prognostic significance of admission glycaemia in a large registry of non-diabetic patients with acute myocardial infarction. METHODS: Assessment of short and long term prognostic significance of admission blood glucose in a consecutive population of 1604 non-diabetic patients admitted to intensive care units in France in November 2000 for a recent (<or= 48 hours) myocardial infarction. RESULTS: In-hospital mortality, compared with that of patients with admission glycaemia below the median value of 6.88 mmol/l (3.7%), rose gradually with each of the three upper sextiles of glycaemia: 6.5%, 12.5% and 15.2%. Conversely, one year survival decreased from 92.5% to 88%, 83% and 75% (p < 0.001). Admission glycaemia remained an independent predictor of in-hospital and one year mortality after multivariate analyses accounting for potential confounders. Increased admission glycaemia also was a predictor of poor outcome in all clinical subsets studied: patients without heart failure on admission, younger and older patients, patients with or without reperfusion therapy, and patients with or without ST segment elevation. CONCLUSION: In non-diabetic patients, raised admission blood glucose is a strong and independent predictor of both in-hospital and long term mortality.

Blood Glucose↗
PubMed2005

[Clinical and therapeutic specificities of myocardial infarction in patients with peripheral arterial disease: the USIC 2000 registry].

OBJECTIVE: Several studies underlined the worse prognosis of myocardial infarction (MI) among patients with peripheral arterial disease (PAD). We sought to describe the presentation and management modalities of a cohort of PAD patients presenting an acute MI, compared to those without PAD. MATERIALS AND METHODS: The USIC 2000 registry, a nationwide database on all patients admitted to a CCU for an acute MI < 48 hours in France in November 2000 was used for this study. RESULTS: Among the 2311 patients included, PAD was reported in 215 subjects (9.3%). In multivariate analysis, the following factors were positively related to the presence of PAD (P < or = 0.05): age >75 y (OR = 2.3), diabetes (OR = 2.0), hypertension (OR = 1.4), active smoking (OR = 4.6), renal failure (OR =3.1), and treatments with antiplatelets (OR = 3.9), anti-vitamin K (OR = 1.9), statins (OR = 1.7) and low molecular weight heparins (OR = 6.8). By introducing the data concerning the arrival in CCUs in the model, the following factors were also significantly more frequent among PAD patients: male sex (OR = 1.6), past history of coronary artery disease (OR = 2.2), left bundle branch block (OR = 1.8) and late management >6 hours (OR = 1.4). Conversely, ST-segment elevation was less frequent (OR = 0.7). When the CCU stay data were introduced in the model, a lower rate of coronary stenting (OR = 0.7) and betablockers use within 48 hours of admission (OR = 0.6) were noted. CONCLUSION: Beyond the presence of PAD per se, several particularities do exist, especially the coexistence of a high number of pejorative factors and an under-utilization of treatments presenting prognostic benefits.

Aged↗
PubMed2005

[Echocardiography and mechanical complications of recent myocardial infarction].

The constantly advancing technology of echocardiography and its widespread usage in the intensive care unit has made it a routine examination in patients with acute myocardial infarction. It has become the reference method for diagnosis and monitoring of certain complications such as pericardial effusion, intra-ventricular thrombosis, ventricular aneurysm and mitral regurgitation. The echocardiographic description of these complications dates back to the 1980s during which prospective studies accurately described the principal abnormalities. These descriptions have not been much improved upon with the advent of new technology. On the other hand, the frequency of these complications assessed in an era when reperfusion by thrombolysis or primary angioplasty was much less common than today, has considerably decreased.

Echocardiography↗
PubMed2005

[Management of patients admitted for acute myocardial infarction in France from 1995 to 2000: time to admission dependent improvement in outcome].

The in-hospital management and short- and long-term outcomes was assessed in 2 registries of consecutive patients admitted for acute myocardial infarction, 5 years apart, in France. The 2000 cohort was younger and with a less frequent history of cardiac diseases, but was more often diabetic and with anterior infarcts. Time to admission was actually longer in 2000 than in 1995 (median 5.25 hours vs 4.00 hours). Overall, reperfusion therapy was used in 43% of the patients in both registries. However, the use of reperfusion therapy increased from 1995 to 2000 in patients admitted within 6 hours of symptom onset (64 vs 58%), with an increasing use of primary angioplasty (from 12 to 30%). Five-day mortality significantly improved from 7.7 to 6.1% (p < 0.03) and one-year survival was also less in the most recent period (85 vs 81%, p < 0.01). Multivariate analyses showed that the period of inclusion (2000 vs 1995) was an independent predictor of both short- and long-term mortality in patients admitted within 6 hours of symptom onset. Thus, in the real world setting, a continued decline in one-year mortality was observed in patients admitted to intensive care units for recent acute myocardial infarction, especially for patients admitted early. This goes along with a shift in reperfusion therapy towards a broader use of primary angioplasty, and with an increased use of the early prescription of recognised secondary prevention medications.

Age Factors↗
PubMed2004

[Evolution of the management and outcomes of patients admitted for acute myocardial infarction in France from 1995 to 2000: data from the USIK 1995 and USIC 2000 nationwide registries].

We assessed the in-hospital management and short- and long-term outcomes of two series of patients admitted for acute myocardial infarction, 5 years apart, in France. The most recent cohort was younger and with a less frequent history of cardiac diseases, but was more often diabetic and with anterior infarcts. Five-day mortality significantly improved from 7.7% to 6.1% (P < 0.03) and 1-year survival was also less in the most recent period (15% versus 19%, P < 0.01). Multivariate analyses showed that the period of inclusion (2000 versus 1995) was an independent predictor of both short- and long-term mortality. In analyses restricted to the patients who were alive by day 5, initial treatment with statins was associated with a 38% decrease in the risk of death at 1 year. Likewise, in patients with left ventricular ejection fraction < or = 35%, the early prescription of ACE inhibitors was associated with a 41% reduction in the risk of 1-year mortality. Thus, in the real world setting, a continued decline in 1-year mortality is observed in patients admitted to intensive care units for recent acute myocardial infarction. This goes along with a shift in reperfusion therapy towards a broader use of coronary angioplasty and with an increased use of the early prescription of recognised secondary prevention medications.

Aged↗
PubMed2004

Management and in-hospital outcome of patients with acute myocardial infarction admitted to intensive care units at the turn of the century: results from the French nationwide USIC 2000 registry.

OBJECTIVE: To assess actual practices and in-hospital outcome of patients with acute myocardial infarction on a nationwide scale. METHODS: Of 443 intensive care units in France, 369 (83%) prospectively collected data on all cases of infarction (within < 48 hours of symptom onset) in November 2000. RESULTS: 2320 patients (median age 68 years, 73% men) were included, of whom 83% had ST segment elevation infarction (STEMI). Patients without STEMI were older and had a more frequent history of cardiovascular disease. Median time to admission was 5.0 hours for patients with and 6.5 hours for those without STEMI. Reperfusion therapy was used for 53% of patients with STEMI (thrombolysis 28%, primary angioplasty 25%). In-hospital mortality was 8.7% (5.5% of patients without and 9.3% of those with STEMI). Multivariate analysis found that age, Killip class, lower blood pressure, higher heart rate on admission, anterior location of infarct, STEMI, diabetes mellitus, previous stroke, and no current smoking independently predicted in-hospital mortality. At hospital discharge, 95% received antiplatelet agents, 75% received beta blockers, and over 60% received statins. Angiotensin converting enzyme inhibitors were prescribed for 40% of the patients without and 52% of those with ST elevation. CONCLUSIONS: This nationwide registry, including all types of centres irrespective of their size and experience, shows continued improvement in patient care and outcomes. Time from symptom onset to admission, however, has not improved in recent years and reperfusion therapy is used for just over 50% of patients with STEMI, with an increasing use of primary angioplasty.

Adult↗
PubMed2004

[Value of the association of D-dimer measurement and the evaluation of clinical probability in a non-invasive diagnostic strategy of pulmonary embolism].

New diagnostic tools in suspected pulmonary embolism complete the classical diagnostic strategy of pulmonary scintigraphy and pulmonary angiography to limit the indications of these two invasive investigations. In a prospective series of 204 consecutive patients with suspected pulmonary embolism the association of D-dimer measurement and clinical probability was assessed for the exclusion of the diagnosis of pulmonary embolism. The D-DI Liatest is a new generation, unitary, rapid and quantitative latex test with a comparative diagnostic performance to that of the reference ELISA test, and well adapted to emergency situations.The clinical probability was assessed by a quantitative score based on past history, clinical symptoms and signs. The positive diagnosis of pulmonary embolism was made by spiral CT scanner and/or pulmonary angiography, associated with Duplex ultrasonography of the leg veins in nondiagnostic results. The prevalence of pulmonary embolism was 42.6% and the absence of anticoagulation in patients considered not to have pulmonary embolism was associated with a thrombo-embolic incidence of 0.9% at 3 months. Fifty-six patients had D-dimer concentrations equal or inferior to the threshold of 500 microg/L; the sensitivity was 99% and the specificity 47% with a negative predictive value of 98% to 100% in cases with a low clinical probability. D-dimer measurement is reliable and has a high cost-benefit value in ambulatory patients with suspected of pulmonary embolism and is even more valuable when the clinical probability of this diagnosis is low.

Female↗
PubMed2003

[Trends in discharge prescriptions for patients hospitalized for acute coronary syndromes in France from 1995 to 2000. Data from the Usik 1995, Prevenir 1, Prevenir 2 and Usic 2000 surveys].

The use of cardiovascular secondary prevention medications in patients with acute coronary syndromes was compared in 4 sequential observational surveys carried out in France from 1995 to 2000. The Usik 1995 and Usic 2000 surveys included patients admitted for acute myocardial infarction, while the 2 Prevenir surveys (1998 and 1999) assessed the medications prescribed in patients with acute coronary syndromes. Antiplatelet agents were prescribed in 91% of the patients in 1995, 93% in 1998 and 1999 and 96% in 2000; for beta-blockers, the respective figures were: 64%, 68%, 75% and 76%. For ACE-Inhibitors, the figures were: 46%, 41%, 41% and 50%. For statins, the prescription increased from 10% to 36%, 59% and 64%. In 1995, 8% of the patients received both antiplatelet agents, beta-blockers and statins (4% of them also had an ACE-Inhibitor); in 2000, the respective figures were 53% and 27%. The results of the recent trials of secondary prevention medications have had a considerable impact on real-life practice in France during the late 1990s.

Acute Disease↗
PubMed2003

Control of diabetes and cardiovascular risk factors in patients with type 2 diabetes: a nationwide French survey.

OBJECTIVES: To evaluate in France in 2001 the therapeutic management and control of diabetes and of modifiable cardiovascular risk factors in patients with type 2 diabetes receiving specialist care. METHODS: The study was proposed to 575 diabetologists across France. The first 8 consecutive ambulatory patients with type 2 diabetes treated by oral antidiabetic drugs (OADs) and/or insulin attending for consultation with a diabetologist were eligible for inclusion in the survey. The following data were collected: demographics, diabetic and cardiovascular history, cardiovascular risk factors, blood pressure, last recorded measurements of HbA(1c) and LDL cholesterol, and details of diabetes medication and cardiovascular medication. RESULTS: 4, 930 patients (53% men) aged 62 +/- 11 years were recruited by 410 specialists in diabetes care. The mean duration of diabetes was 12 +/- 9 years. 71% of patients were treated with OADs, 18% with an OAD + insulin and 9% with insulin alone. Mean HbA(1c) was 7.6 +/- 1.6%; HbA(1c) was<=6.5% in 27% of patients, between 6.6% and 8% in 39% of patients, and > 8% in 34% of patients. Mean blood pressure was 140 +/- 16/80 +/- 9 mmHg. In the study population as a whole the target blood pressure (systolic BP<140 mmHg and diastolic BP<80 mmHg) was attained by 29% of patients. Among the 3, 085 patients (63%) treated for hypertension, this target was attained in only 23% of patients; 40% of patients treated for hypertension received one single antihypertensive treatment, 36% received 2 treatments and 24% received 3 treatments or more. Among the 1, 845 patients considered by the investigators as not having hypertension, the target blood pressure was attained by 39%. A measurement for LDL cholesterol was available in 4, 036 patients (82%). 58% of these patients had LDL cholesterol<1.3 g/l, 29% had values between 1.3 and 1.6 g/l, and 13% had values > 1.6 g/l. 52% of patients were not receiving any lipid-lowering agents, 28% were treated with statins, 19% with fibrates, and 1% with statins + fibrates. LDL cholesterol was<1.3 g/l in only 66% of the 646 patients with associated coronary heart disease. CONCLUSION: According to this large nationwide survey, the prevalence of cardiovascular risk factors remains high. Control of glycaemia, blood pressure and LDL cholesterol does not appear to be optimal. This is due in part to the severity of diabetes in these patients seen by specialists in diabetes care; however, both awareness and application of published recommendations need to be reinforced.

Analysis of Variance↗
PubMed2003

Impact of microvascular integrity and local viability on left ventricular remodelling after reperfused acute myocardial infarction.

OBJECTIVE: To assess left ventricular remodelling in patients with reperfused acute myocardial infarction and to study its relation to microvascular damage. PATIENTS: 25 patients successfully treated by primary percutaneous coronary angioplasty for acute myocardial infarction. SETTING: University hospital METHODS: Indexed end diastolic (EDVi) and end systolic (ESVi) volumes were assessed on admission and repeated at days 1 and 8. Coronary flow reserve (CFR) was assessed in the infarct related artery on day 1. Myocardial blood volume was assessed on admission and at day 8 by myocardial contrast echocardiography. In patients who manifested persistent myocardial dysfunction at hospital discharge (n = 21), local inotropic reserve was assessed by dobutamine echocardiography at day 7. RESULTS: On admission, patients with and without local viability had similar EDVi and ESVi (EDVi 67 (9) and 73 (14) ml/m(2), respectively; ESVi 34 (8) and 40 (11) ml/m(2), respectively; NS). EDVi increased to 97 (22) ml/m(2) in patients without local viability (p < 0.01 v admission) but remained unchanged at 70 (11) ml/m(2) in patients with viable myocardium (NS v admission). For pooled patient data, the percentage change in EDVi correlated with CFR (r = 0.76, p < 0.0001) and myocardial blood volume in the infarct territory (r = 0.80, p < 0.0001). CONCLUSION: Left ventricular dilatation may preferably occur in patients without local viability and is correlated with early CFR and extent of myocardial blood volume in the infarct territory.

Blood Volume↗
PubMed2003

[Calcified aortic stenosis with left ventricular dysfunction and low transvalvular gradients. Must one reject surgery in certain cases?].

The natural history of severe aortic stenosis (aortic valve area < 1 cm2 or < 0.6 cm2/m2) with left ventricular systolic dysfunction and low transvalvular gradients (mean gradient < 40 mmHg) is mediocre in the short term and the operative risk is high. Dobutamine echocardiography provides a reliable evaluation of the aortic obstacle by diagnosing the rare cases of relative aortic stenosis in which the valve surface area has been underestimated because of a low cardiac output (aortic surface area > 1.2 cm2 with a mean gradient < 30 mmHg with dobutamine): in this case, the limited available data suggests that medical therapy with strict follow-up of its efficacy is the best management. The other use of dobutamine echocardiography is to assess left ventricular contractile reserve, defined as a increase > or = 20% in stroke volume under dobutamine. Cases with a contractile reserve have an operative risk of 5 to 10% and the medium-term benefits of valve replacement have been demonstrated. In the absence of contractile reserve, the operative risk is much grater, 30 to 60%, and also depends on other parameters such as the mean basal transaortic pressure gradient (risk five times greater in cases with a mean gradient < 20 mmHg), the need for coronary bypass surgery and associated co-morbid conditions. The surgical contraindications are in fact relatively few and concern patients with several risk factors: absence of contractile reserve itself is not a definitive surgical contraindication.

Aortic Valve Stenosis↗
PubMed2002

Efficacy of very low dose perindopril 2 mg/indapamide 0.625 mg combination on left ventricular hypertrophy in hypertensive patients: the P.I.C.X.E.L. study rationale and design.

The PICXEL study is designed to evaluate the effects of long-term administration of very low-dose combination perindopril 2 mg/indapamide 0.625 mg (Per/Ind) vs enalapril in reducing left ventricular hypertrophy (LVH) in hypertensive patients. This multicentre, controlled, randomised, double-blind, parallel group study is carried-out to assess the variation of left ventricular mass index (LVMI) after treatment, using a centralised control of M-mode echocardiography determinations, and a dedicated software for semi-automatic measurement. Following a 4-week placebo run-in period, hypertensive outpatients aged >/=18 years, with LVH (LVMI >120 and 100 g/m(2) for men and women, respectively), are randomised to receive once daily, over 52 weeks, either Per/Ind or enalapril. According to blood pressure levels, the dose may be adjusted. In addition to clinical examinations, ECG, blood pressure, heart rate and laboratory assessments echocardiographic determinations are performed for selection, at baseline, after 24 weeks and at the end of the study. The main outcome criteria is the change from baseline in LVMI which is considered the primary efficacy criterion; changes in blood pressure and echo-Doppler parameters constitute secondary criteria. Two-sided Student's t-test for independent samples will be used to differentiate the effects of the treatment between groups with alpha = 5%, and the inter-group difference of LVMI variation will be analysed with a power of 90%. A sample size of 500 patients is required making it necessary to randomise at least 550 patients, based on a 10% proportion of potentially non-assessable patients. The results of this study, obtained after applying strict methodological procedures and requirements, are expected to provide valuable and reliable information on the effects of long-term administration of Per/Ind on LVH, and on its potential superiority over enalapril.

Angiotensin-Converting Enzyme Inhibitors↗
PubMed2002

[Changes in left ventricular torsion during ischemia-reperfusion].

We aimed to characterise the alterations of left ventricular twist during ischaemia-reperfusion and to study their relationship to global left ventricular function. Systolic left ventricular twist was measured at the mid-papillary muscle level by colour tissue Doppler echocardiography in 7 anaesthetised open-chest dogs at baseline, 90 min-occlusion of the left anterior descending, and 180 min after reflow. Tissue Doppler was also performed in 34 patients after anterior infarct and in 20 controls. In controls, rotation occurred counterclockwise when viewed from the base. In a random subset of subjects, the assessment of ventricular twist by tissue Doppler was validated against magnetic resonance myocardial tagging. Myocardial ischaemia led to a decrease in ventricular twist in dogs and infarct patients (p < 0.01). This decrease was correlated with the extent of the asynergic area and global left ventricular function (p < 0.001). In dogs, cardiac twist was higher after reflow relative to ischaemia (p < 0.01). Thus, acute myocardial ischaemia is responsible for a decrease in left ventricular twist that is related to global ventricular function. Colour tissue Doppler echocardiography provides straightforward assessment of left ventricular twist in humans.

Aged↗
PubMed2002

[Can stress echocardiography by quantified?].

Stress echocardiography has been validated for the evaluation of myocardial ischaemia and viability despite a semi-quantitative interpretation based on visual analysis of segmental myocardial thickening. The technique remains, therefore, partially subjective, which probably affects its diagnostic value and reproducibility, especially during the learning period of a non-expert operator. A first step towards better reproducibility was made possible by Second Harmonic imaging and standardised interpretation according to the recommendations of the American Society of Echocardiography. The quantification is based on the analysis of numerical data obtained by Doppler tissue imaging or color kinesis. Doppler Tissular Imaging in the pulsed mode with analysis of transparietal velocity gradients or regional deformation is currently under evaluation. However, the use of threshold values for myocardial velocities has been of little diagnostic value and the use of algorithms adjusted for age, heart rate and gender are necessary. Another approach is that of colour coding of endocardial displacement (Color Kinesis) with automatic contour detection. This relatively easy technique requires a shorter post-processing and the initial results are encouraging.

Echocardiography, Doppler, Color↗