Agrément FMC N° 100 437

Conflits d’intérêt

Astra-Zeneca, BMS, MSD, Novartis,

Pfizer, Daiichi-Sankyo, Servier,

CRAM, AFSSAPS, ARH

Région de Bourgogne

Clos Vougeot

Nord

Haute-Garonne

Haute-Savoie

Côte-d’Or

Essonne

Popul.millions

Areakm2

Densityinha/km2

NORD 2,5 5 743 447Essonne 1,2 1 804 668Hte Garonne

1,2 6 309 193

Hte Savoie

0,7 4 388 163

Côted’Or

0,5 8 763 60

# 6

Côte-d’Or : 29Haute-Garonne : 39Nord : 57Haute-Savoie : 37Essonne : 38

Almost 3/4 of males : 72,5 % male

Demographic characteristics

200 patients analysed

– Mean age : 63,3 yrs with regional differences : 69,4 yrs in Côte-d’Or 60,0 yrs in Essonne

Demographic characteristics

– More than half of patients retired (54 %), with regional differences

74,1 % in Côte-d’Or 40,5 % in Essonne

– Hypertension : 43,5 %– Diabetes : 21,4 %– Active smoking : 44,9 %– Mean weight : 77 kg– BMI ≥ 30 : 20,8 %

Risk factors and medical history

– CAD known prior to admission : 19,7 %

– In 3/4 of cases (71,1 %), chest pain triggers a phone call

– Emergency number 15 : only in 49 % of cases

First aid

– Chest pain reported in 93,9 % of cases

– Emergency ambulance (SAMU/SMUR) is the 1st medical contact in less than 50 % of cases

• Patients without reperfusion : older Half are female ¼ are employed

Revascularisation modesFibrinolysis Primary PCI no reperfusion p

Population

AgeFemale (%)Occupation (%)

EmployedUnemployed

Retired

22 %

63 ± 1323 %

445,1

51,3

64 %

62 ± 1324 %

418,1

50,5

14 %

70 ± 1250 %

224,3

73,9

< 0,001

< 0,01< 0,02

0,32

Widimsky P et al, Eur Heart J 2010; 31:943-57.

Primary PCI Thrombolysis No reperfusion

France

64

22

14

Patients referred directly to an interventional cardiology unit

Preferred strategy is direct hospitalisation to cath-lab 64 %  as an average

70,2 % if patient referred by medical ambulance

1er call Admission P PCI

20 min33 min 54 min 43 min

97 min

symptom onset

FMC

Symptom onset

Patients referred to peripheral centres

Admission to the cath lab P PCI

163 min

227 min204 min

• Mean delay was more than double

FMC

Effects of numbers of actors

4,25,5

9,7

% h

ospi

tal m

orta

lity

Nr of actors

USIK

1995

2152

patients

373 centres

1536 STEMI

Population

USIC

2000

2320

patients

369 centres

1844 STEMI

FAST-MI

2005

3059

patients

223 centres

1611 STEMI

FAST-MI

2010

3069

patients

213 centres

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

NSTEMI38+11.5% call SAMU first21% call their GP first 19% go to ER 29+8% call SAMU first

27% call their GP first19% go to ER

Increased % of younger women

Time to first call in STEMI patients

% 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

2.12.6

- 48 % - 74 % - 70 %

30-day mortality: STEMI & NSTEMI

5 ?

Mortality according to timing of PCI after thrombolysis

FAST-MI 2005

No PCI PCI ≤128 minutes PCI 129-220 minutes PCI > 220 minutes

Systematic pharmaco-invasive

Rescue or symptom-driven PCI

All patients with PCI after lysis

Genetic determinants of clopidogrel response and clinical events in FAST-MI 2005

Simon et al. NEJM 2009

FAST-MI registry

2,208 patients withAMI, followed for one year

Number of CYP2C19 loss-of-function alleles

Early prescription of statins is associated with lower risk of developing acute AF

Danchin et al. Heart 2010

% of patients developing AF

LMWH vs UFH in elderly patients

Puymirat et al. Int J Cardiol 2012

Survival in propensity score-matched cohorts

Standard vs loading dose of clopidogrel in elderly patients: FAST-MI 2005

Puymirat et al. Am J Cardiol 2011

One-year event-free survival

Adjusted HR (95%CI): 0.92 (0.68-1.25)

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.