FAST-MI Registry Research Articles

P3644High-grade atrioventricular block in acute myocardial infarction: evolution of prevalence, patient profile, management and outcomes, 1995-2010. Insights from FAST-MI Registries

P3644High-grade atrioventricular block in acute myocardial infarction: evolution of prevalence, patient profile, management and outcomes, 1995-2010. Insights from FAST-MI Registries

Le syndrome coronaire aigu avec sus-décalage du segment ST chez la femme

In France, coronary disease is responsible for 11.9 deaths/100,000 women aged 35 to 74 years old every year. In France, the number of hospitalizations and deaths for myocardial infarction (MI) increases more significantly in women, particularly under 65. To date, women with MI were 5–10 years older than men, with more risk factors and comorbidities, especially regarding diabetes, high blood pressure and lipid profile. However, a recent comparative study of the FAST-MI registry notes a change in the characteristics of these patients with more and more young women, active smoking and obesity. Their symptoms include more often atypics ones. They also have the particularity of a higher frequency of MI without obstructive lesion. Though, even at the same age, women have a worse prognosis with significantly higher mortality rate, especially early, in-hospital, than those of men. However, there are means to implement in order to reduce complications rate and improve the prognosis through information campaign and primary prevention screening and appropriate care and correction of risk factors. It is also important to raise awareness of general population and care actors about women MI risk even young, about its atypical forms and the necessity of to rapid and aggressive care processes. A better understanding of specific pathophysiological mechanisms appears mandatory and should be supported by prospective dedicated studies.

Patients with non-ST-elevation acute coronary syndrome managed without coronary revascularization: an undertreated population

Non-ST-elevation acute coronary syndromes (NSTE-ACS) represent one of the most common clinical presentations of ischemic heart disease. Patients with NSTE-ACS are a heterogeneous population, with different clinical features and prognosis. A significant proportion of this population is medically managed, without any revascularization. In the Italian EYESHOT and French FAST-MI registries, patients managed with a conservative strategy were 40% and 35%, respectively. NSTE-ACS patients not undergoing coronary revascularization are at higher risk of adverse cardiovascular events and have a worse prognosis, including short- and long-term mortality, compared with those receiving revascularization. Patients with NSTE-ACS medically managed consist of three different subgroups: those not undergoing coronary angiography, those receiving coronary angiography and without significant coronary artery disease, and those with significant coronary artery disease at angiography but not receiving revascularization. Patients presenting with NSTE-ACS for whom a conservative strategy without coronary angiography is planned should be selected very carefully and coronary angiography should not be denied because of the lack of on-site cath-lab facilities. In addition, advanced age alone, in the absence of severe comorbidities or frailty, should not be considered as a reason for denying coronary angiography and, in general, optimal treatment. Given that evidence-based data are lacking, a careful balance between benefits and risks is needed in the decision to perform or not coronary angiography and/or revascularization in patients with important comorbidities, or frailty, or advanced age. In this decisional process, it should be also taken into consideration the role of coronary anatomy in risk stratification and treatment guidance.NSTE-ACS patients managed without revascularization less frequently receive guideline-recommended pharmacological treatment. Dual antiplatelet therapy is recommended for 12 months also in medically managed patients, after careful balance of ischemic and bleeding risk. Indeed, in this group of patients it is mandatory to optimize pharmacological treatment, including antiplatelet therapy, in order to improve clinical outcome. In NSTE-ACS not undergoing revascularization, the proportion of patients discharged with dual antiplatelet therapy should be increased in comparison to current clinical practice, and the use of ticagrelor instead of clopidogrel should be considered in selected patients.

Blood transfusion, bleeding, anemia, and survival in patients with acute myocardial infarction: FAST-MI registry

An association between transfusion during index hospitalization and increased subsequent mortality has been reported in acute myocardial infarction (AMI). Whether this reflects the prognostic role of transfusion per se, or the impact of the index event leading to transfusion, remains unclear. We sought to evaluate the impact of transfusion on mortality in patients with AMI. Using the nationwide FAST-MI 2005 AMI registry, we recorded anemia on admission, Thrombolysis in Myocardial Infarction major or minor bleeding, and transfusions during hospital stay. Multivariable analyses were performed to identify independent predictors of in-hospital and 5-year mortality. Cohorts of patients matched for propensity to receive transfusion were compared. Among 3541 patients with AMI, 827 (23.4%) had anemia on admission, 114 (3.2%) had minor or major bleeding, and 151 (4.3%) underwent transfusion. After multivariable analysis, both anemia and bleeding were independently associated with 5-year mortality (hazard ratio [HR] 1.4, 95% CI 1.2-1.6 and HR 1.4, 95% CI 1.1-1.8, respectively), whereas transfusion did not appear to be an independent predictor (HR 1.1, 95% CI 0.8-1.5). Mortality at 5 years did not differ between cohorts matched for propensity to receive transfusion. In this cohort, anemia on admission and bleeding during hospitalization were both associated with increased 5-year mortality in patients with myocardial infarction. Conversely, transfusion per se was not associated with lower survival. Further work is needed to clarify the optimal transfusion strategy in patients with bleeding or anemia and myocardial infarction.

Impact of age-adjusted insulin-like growth factor i on major Cardiovascular events Two Years after acute Myocardial infarction: results from the fast-mi registry

Impact of age-adjusted insulin-like growth factor i on major Cardiovascular events Two Years after acute Myocardial infarction: results from the fast-mi registry

Impact of age-adjusted insulin-like growth factor 1 on major cardiovascular events after acute myocardial infarction: results from the fast-MI registry.

The GH/IGF-1 axis is being targeted for therapeutic development in diseases such as short stature, cancer, and metabolic disorders. The impact of IGF-1 in cardiovascular disease remains controversial. We therefore studied whether IGF-1 at admission for acute myocardial infarction (AMI) predicted death, recurrent AMI, and stroke over a 2-year follow-up. Using data from the French registry of Acute ST-elevation and non-ST-elevation Myocardial Infarction registry, we measured IGF-1 among all the 1005 patients with AMI who participated in the serum data bank. Because IGF-1 decreases with age, a standardized IGF-1 score was calculated as previously described [IGF-1 score = (log [IGF-1 (micrograms per liter)] + 0.00625 × age - 2.555)/0.104]. Impact of IGF-1 score (continuous and quartiles) on outcomes were compared using Cox proportional hazards regression models. During follow-up, 190 patients died or had a recurrent AMI or stroke. Patients in the lowest quartile of IGF-1 were older and more frequently female and diabetic compared with patients in the other quartiles. After adjustment for known cardiovascular factors, an increase of five units of IGF-1 score was associated with a 30% decrease of the risk of events during follow-up (adjusted hazard ratio 0.70; 95% confidence interval 0.54-0.92; P = .0093). Similarly, the lowest quartile of IGF-1 was associated with an increased risk of events (adjusted hazard ratio 1.52, 95% confidence interval 1.11-2.08; compared with others quartiles, P = .010). Low IGF-1 score is associated with an increased risk of all-cause death, recurrent myocardial infarction, and stroke in AMI patients. Whether patients treated by IGF-1 axis inhibitors have a specific clinical course after AMI would be worth studying.

Limitaciones de los programas regionales de angioplastia coronaria primaria: ¿la estrategia farmacoinvasiva todavía es una alternativa?

All guidelines recommend primary percutaneous coronary intervention as the default strategy for achieving reperfusion in ST-segment elevation myocardial infarction patients. These recommendations are based upon randomized trials which compared primary percutaneous coronary intervention with stand-alone intravenous fibrinolysis. Since the time these trials were performed, however, it has been shown in further trials that use of rescue percutaneous coronary intervention in patients without signs of reperfusion after lysis, and routine coronary angiography within 24h of the administration of lysis for all other patients, substantially improved the results of intravenous fibrinolytic treatment. This has led to proposing the pharmaco-invasive strategy as an alternative to primary percutaneous coronary intervention. Actually, it is not uncommon that circumstances prevent performing primary percutaneous coronary intervention within the recommended time limits set by the guidelines. In such cases, using a pharmaco-invasive strategy may constitute a valid alternative. Both the STREAM randomized trial and real-world experience, in particular the long-term results from the FAST-MI registry, suggest that the pharmaco-invasive strategy, when used in an appropriate population, compares favorably with primary percutaneous coronary intervention. Therefore, implementing a pharmaco-invasive strategy protocol may be an important complement to compensate for potential weaknesses in ST-segment elevation myocardial infarction networks.Full English text available from:www.revespcardiol.org/en

Weaknesses in Regional Primary Coronary Angioplasty Programs: Is There Still a Role for a Pharmaco-invasive Approach?

All guidelines recommend primary percutaneous coronary intervention as the default strategy for achieving reperfusion in ST-segment elevation myocardial infarction patients. These recommendations are based upon randomized trials which compared primary percutaneous coronary intervention with stand-alone intravenous fibrinolysis. Since the time these trials were performed, however, it has been shown in further trials that use of rescue percutaneous coronary intervention in patients without signs of reperfusion after lysis, and routine coronary angiography within 24h of the administration of lysis for all other patients, substantially improved the results of intravenous fibrinolytic treatment. This has led to proposing the pharmaco-invasive strategy as an alternative to primary percutaneous coronary intervention. Actually, it is not uncommon that circumstances prevent performing primary percutaneous coronary intervention within the recommended time limits set by the guidelines. In such cases, using a pharmaco-invasive strategy may constitute a valid alternative. Both the STREAM randomized trial and real-world experience, in particular the long-term results from the FAST-MI registry, suggest that the pharmaco-invasive strategy, when used in an appropriate population, compares favorably with primary percutaneous coronary intervention. Therefore, implementing a pharmaco-invasive strategy protocol may be an important complement to compensate for potential weaknesses in ST-segment elevation myocardial infarction networks.

Impact of chronic obstructive pulmonary disease on early and late mortality in patients after an acute myocardial infarction. Insights from FAST-MI 2005 registry

Background: Patients with chronic obstructive pulmonary disease (COPD)have worse prognosis after acute myocardial infarction (AMI) but it remains unclear whether this is related to comorbidities, inadequate treatment, or to the COPD itself. Using data from the FAST-MI registry, we investigated the impact of history of COPD on acute and long term outcomes after MI. Methods: FAST-MI 2005 included consecutive patients with AMI over 1 month in 223 French centres. Baseline characteristics and hospital management were compared between groups according to COPD status at inclusion. All-cause mortality at 30 days and 5 year were compared between COPD group using Cox multivariate analysis and paired comparison (matched pairs on a propensity score to have a history of COPD) Results: Among 3670 AMI patients included, 179 (5%) had a history of COPD. COPD pts were older, had more diabetes, previous stroke, heart and renal failure and higher GRACE score. They less often received betablockers, coronary angiography and reperfusion/revascularisation. In-hospital death was twice as high in CPD patients (12.8% vs 5.2%, p<0.0001), as was 5 year mortality (58% vs 28%), p<0.001). After adjustment for baseline characteristics, comorbidities and hospital management, COPD was associated with higher 30-day (hazard ratio, HR 2.4 [1.2; 4.5]) and 5 year mortality (HR 1.6 [1.4; 1.8]) in the overall population and higher 5 year mortality among survivors at 30 days (HR 2.3 [1.9; 2.8]). After matching on a propensity score (132 pairs), there was no difference in in-hospital mortality, but 5 year mortality remained higher in COPD patients (56.1% vs 41.7%, p=0.02). ![Figure][1] Conclusions: COPD patients represent a high risk subgroup for early and long term death, irrespective of co-morbidities and hospital management. [1]: pending:yes

Cardiac rehabilitation and five-year mortality after an acute coronary syndrome: the 2005 French FAST-MI registry

Cardiac rehabilitation and five-year mortality after an acute coronary syndrome: the 2005 French FAST-MI registry

Canada Acute Coronary Syndrome Risk Score: A new risk score for early prognostication in acute coronary syndromes

Despite the availability of several acute coronary syndrome (ACS) prognostic risk scores, there is no appropriate score for early-risk stratification at the time of the first medical contact with patients with ACS. The primary objective of this study is to develop a simple risk score that can be used for early-risk stratification of patients with ACS. We derived the risk score from the Acute Myocardial Infarction in Quebec and Canada ACS-1 registries and validated the risk score in 4 other large data sets of patients with ACS (Canada ACS-2 registry, Canada-GRACE, EFFECT-1, and the FAST-MI registries). The final risk score is named the Canada Acute Coronary Syndrome Risk Score (C-ACS) and ranged from 0 to 4, with 1 point assigned for the presence of each of these variables: age ≥75 years, Killip >1, systolic blood pressure <100 mm Hg, and heart rate >100 beats/min. The primary end points were short-term (inhospital or 30-day) and long-term (1- or 5-year) all-cause mortality. The C-ACS has good predictive values for short- and long-term mortality of patients with ST-segment elevation myocardial infarction and non-ST-segment elevation ACS. The negative predictive value of a C-ACS score ≥1 is excellent at ≥98% (95% CI 0.97-0.99) for short-term mortality and ≥93% (95% CI 0.91-0.96) for long-term mortality. In other words, a C-ACS score of 0 can potentially identify correctly ≥97% short-term survivors and ≥91% long-term survivors. The C-ACS risk score permits rapid stratification of patients with ACS. Because this risk score is simple and easy to memorize and calculate, it can be rapidly applied by health care professionals without advanced medical training.

012: Use of invasive strategy in non-ST-elevation myocardial infarction is a major determinant of improved long-term survival. The FAST-MI registry

We assessed the impact of invasive strategy (IS) versus a conservative strategy (CS) on in-hospital complications and three-year outcomes in patients with Non-ST-Elevation Myocardial Infarction (NSTEMI) from the FAST-MI registry. Results from randomized trials comparing IS and CS in patients with NSTEMI are conflicting. Of the 3,670 patients in the FAST-MI registry, which included patients with acute myocardial infarction (within 48 hours) over a one-month period in France at the end of 2005, 1,645 presented with NSTEMI. Of the 1,645 patients analyzed, 80% had an IS. Patients in the IS group were younger (67±12 vs. 80±11 years), less often women (29% vs. 51%) and had a lower GRACE risk score (137±36 vs. 178±34) as compared with patient treated with CS. In-hospital mortality and blood transfusions were significantly more frequent in patients with CS as compared with IS (13.1 vs. 2.0%, 9.1 vs. 4.6%). Use of IS was associated with a significant reduction in 3-year mortality and cardiovascular death (17% vs. 60%, adjusted HR: 0.44; 95%CI: 0.35-0.55 and 8% vs. 36%, adjusted HR: 0.37; 95%CI: 0.27-0.50). After propensity score matching (181 patients per group), 3-year survival was significantly higher in patients treated with IS. In a real-world setting of patients admitted with NSTEMI, the use of IS during the initial hospital stay is an independent predictor of improved 3-year survival, regardless of age.

010: Prediction of long-term survival in patients receiving optimal secondary prevention therapy after acute myocardial infarction: the FAST-MI registry

Predictors of long-term outcome in optimally-treated patients after AMI have not been extensively studied. We assessed 3-year survival in a population of 3,262 patients from the FAST-MI registry who were discharged alive after the acute episode. At hospital discharge, 1586 patients (49%) received optimal medical treatment (OMT: antiplatelet + beta-blocker + statin + ACE-I or ARB agents). Patients receiving OMT were younger (64±13 vs 69±14 years, p<0.001), had a lower GRACE risk score (141 ±33 vs 151±36, p<0.001)and had more use of PCI during index hospitalization (75% vs 56%, p<0.001). Three-year survival was 88% in patients with OMT versus 77.5% in patients without (p<0.001). Cox multivariate analysis was used to determine predictors of 3-year mortality and covariates included age, sex, risk factors, comorbidities, type of AMI, CAD extent, use of PCI, use of CABG, in-hospital complications, and other discharge medications. Overall, adjusted HR for 3-year death was 0.82 (0.68-1.00), p=0.048, for patients receiving OMT, confirming the benefit of comprehensive therapy beyond each of its individual components. In the 1586 patients receiving OMT at discharge, independent predictors of long-term death were age ≥75 years [HR 1.93 (1.03-3.64)]; AMI type and severity [STEMI vs NSTEMI: HR 0.64 (0.44-0.93); GRACE score: HR 1.01 (1.00-1.01); LVEF< 40%: HR 2.03 (1.31-3.16); 3-vessel CAD: HR 2.12 (1.28-3.52)]; previous CV history [stroke: HR 1.91 (1.29-2.83), CHF: HR 1.79 (1.11-2.88)]; management with an invasive strategy [HR 0.31 (0.17-0.56)], and associated conditions [history of diabetes HR 1.79 (1.28-2.49); history of cancer HR 2.76 (1.75-4.33); current smoking at the time of AMI HR 1.88 (1.20-2.94)]. In patients receiving OMT after AMI, early invasive management remains a significant predictor of improved survival, while associated non cardiac conditions (and in particular cancer, diabetes, previous TIA or stroke, and smoking) are major determinants of higher long-term mortality.

009: Comparison of bleeding complications and three-year survival of low molecular weight heparin versus unfractioned heparin for acute myocardial infarction. The FAST-MI registry

Recent clinical studies suggest that low molecular weight heparin (LMWH) could be an effective and safe alternative to unfractionated heparin (UFH) for patients with acute myocardial infarction (AMI). To assess the impact of the choice of anticoagulant (LMWV vs. UFH) on bleeding, the need for blood transfusion and three-year clinical outcomes in patients with AMI from the FAST-MI registry. FAST-MI is a nationwide registry carried out in France over a 1-month period in 2005, including consecutive patients with AMI admitted to intensive care unit <48h from symptom onset in 223 participating centers. 2854 patients treated with heparins were included. The risk of major bleeding or transfusion (3.0% vs. 7.0%) and in-hospital death (3.2% vs 9.2%) was lower with LMWH compared with UFH, a difference that persisted after multivariate adjustment (OR=0.51, 95% CI: 0.34-0.76 and OR=0.53, 95% CI: 0.37-0.76, respectively). Three-year survival and stroke and reinfarction-free survival were also higher with LMWH compared with UFH (adjusted HR =0.73, 95% CI: 0.61-0.86 and HR =0.73, 95% CI: 0.62-0.85, respectively). In two cohorts of patients matched on a propensity score for getting LMWH and with similar baseline characteristics (834 patients per group), major bleeding and transfusion were lower while three-year survival was signicantly higher in patients receiving LMWH. The present data suggest that the use of LMWH in AMI patients may have a better benefit/risk profile than UFH with in terms of bleeding, need for transfusion, and long term survival.

251: Statins after an acute coronary syndrome: are high doses useful? Data from the French FAST-MI registry

The beneficial effect of a high dose of statin (HDS) compared with lower doses is controversial in secondary prevention. We studied factors impacting the prescription of a HDS at discharge after an Acute Myocardial Infarction [AMI], and assessed effects of this HDS on mortality and cardiovascular morbidity. Participants were 2240 survivors of a STEMI or NSTEMI from the French FAST-MI registry conducted in 2005, with a known statin dose at discharge. Rosuvastatin at any dose, atorvastatin ≥20 mg/d and Simvastatin 40 mg/d were considered as HDS. Factors related to HDS prescription were studied using logistic regression. Impact of HDS prescription on occurrence of death or major cardiovascular events [MACE] (MI, stroke or revascularisation) was studied using a Cox proportional hazards model after propensity score matching. 54.5% of the patients had a HDS prescription at discharge. In crude risk analyses, HDS prescription was associated with a lower risk of death or MACE (HR=0.84 [0.71-0.98], p<0.03). However, patients already under treatment with a HDS before the ACS, patients managed in a university hospital, located in a large city, with a younger age, a STEMI, a high blood pressure at entry (≥140 mmHg) and who were discharged rapidly after their AMI were more likely to benefit from a HDS prescription at discharge. After propensity score matching, the dose of statin the patients received at discharge was not related to death or MACE occurrence in the following 3 years (HR=1.04 [0.77-1.36], p=0.87). Using a more stringent definition for HDS (atorvastatin ≥40 mg or rosuvastatin ≥20 mg) yielded similar results. The issue of long term benefit of HDS therapy compared with lower ones after an AMI remains unanswered in an observational context, because in this “real life” large registry, high doses were preferentially prescribed to patients with a low risk profile, but less commonly to patients with a high risk profile.

Comparison of bleeding complications and 3-year survival with low-molecular-weight heparin versus unfractionated heparin for acute myocardial infarction: The FAST-MI registry

Recent clinical studies suggest that low-molecular-weight heparin (LMWH) could be an effective and safe alternative to unfractionated heparin (UFH) for patients with acute myocardial infarction (AMI). To assess the impact of anticoagulant choice (LMWV vs UFH) on bleeding, the need for blood transfusion and 3-year clinical outcomes in AMI patients from the FAST-MI registry. FAST-MI was a nationwide registry compiled in France over 1 month in 2005, which included consecutive AMI patients admitted to an intensive care unit less than 48 hours from symptom onset in 223 participating centres. A total of 2854 patients treated with heparins were included. The risks of major bleeding or transfusion (3.0% vs 7.0%) and in-hospital death (3.2% vs 9.2%) were lower with LMWH compared with UFH, a difference that persisted after multivariable adjustment (odds ratio [OR] 0.51, 95% confidence interval [CI] 0.34-0.76 and OR 0.53, 95% CI 0.37-0.76, respectively). Three-year survival, and stroke and reinfarction-free survival risks were also higher with LMWH compared with UFH (adjusted hazard ratio [HR] 0.73, 95% CI 0.61-0.87 and HR 0.73, 95% CI 0.62-0.85, respectively). In two cohorts of patients matched on propensity score for receiving LMWH and with similar baseline characteristics (834 patients per group), major bleeding and transfusion rates were lower while the 3-year survival rate was significantly higher in patients receiving LMWH. Our data suggest that the use of LMWH in AMI patients may have a better benefit/risk profile than UFH, in terms of bleeding, need for transfusion and long-term survival.

Heart Failure in Acute Myocardial Infarction: a Comparison Between Patients With or Without Heart Failure Criteria From the FAST-MI Registry

Introduction and objectivesTo compare acute myocardial infarction patients with or without congestive heart failure in the French FAST-MI registry. MethodsThe French FAST-MI registry included 374 centers and 3059 patients over a 1-month period at the end of 2005, with 1-year follow-up. Among this population, patients with at least one congestive heart failure criterion constituted group 1 (n=1149; 37.5%) and were compared to patients without congestive heart failure (group 2, n=1910; 62.5%). The congestive heart failure patients were further divided according to presence of both beta-blockers and antagonists of the renin-angiotensin-aldosterone system at hospital discharge (n=511) or not (n=498), in order to assess the real-world clinical importance of recommended medications. ResultsOverall in-hospital and 1-year mortality rates were 3.4% and 13.2%, respectively. In hospital survivors, presence of congestive heart failure was associated with increased mortality (adjusted hazard ratio=1.55; 95% confidence interval, 1.10-2.17; P=.01). Survival was higher in patients without congestive heart failure, compared with congestive heart failure patients receiving or not recommended medications (P<.001). Congestive heart failure patients receiving neither renin-angiotensin-aldosterone system blockers nor beta-blockers (adjusted hazard ratio=1.66; 95% confidence interval, 1.08-2.55; P=.02) had a significantly higher risk of death than patients receiving both classes of medications (adjusted hazard ratio=1.16; 95% confidence interval, 0.82-1.64; not statistically significant). Patients receiving only one of the recommended classes had an intermediate risk (adjusted hazard ratio=1.47; 95% confidence interval, 1.04-2.07; P=.03). ConclusionsPatients admitted for acute myocardial infarction with congestive heart failure criteria are still at very high risk of mortality. When receiving major recommended medications, they presented with significantly reduced mortality rates. Additional efforts should therefore be made to encourage the prescription of recommended medications in acute myocardial infarction patients with congestive heart failure.Trial registration: ClinicalTrials.gov number: NCT00673036.

Insuficiencia cardiaca en el infarto agudo de miocardio: comparación de pacientes con o sin criterios de insuficiencia cardiaca del registro FAST-MI

Introduction and objectivesTo compare acute myocardial infarction patients with or without congestive heart failure in the French FAST-MI registry. MethodsThe French FAST-MI registry included 374 centers and 3059 patients over a 1-month period at the end of 2005, with 1-year follow-up. Among this population, patients with at least one congestive heart failure criterion constituted group 1 (n=1149; 37.5%) and were compared to patients without congestive heart failure (group 2, n=1910; 62.5%). The congestive heart failure patients were further divided according to presence of both beta-blockers and antagonists of the renin-angiotensin-aldosterone system at hospital discharge (n=511) or not (n=498), in order to assess the real-world clinical importance of recommended medications. ResultsOverall in-hospital and 1-year mortality rates were 3.4% and 13.2%, respectively. In hospital survivors, presence of congestive heart failure was associated with increased mortality (adjusted hazard ratio: 1.55; 95% confidence interval, 1.10-2.17; P=.01). Survival was higher in patients without congestive heart failure, compared with congestive heart failure patients receiving or not recommended medications (P<.001). Congestive heart failure patients receiving neither renin-angiotensin-aldosterone system blockers nor beta-blockers (adjusted hazard ratio: 1.66; 95% confidence interval, 1.08-2.55; P=.02) had a significantly higher risk of death than patients receiving both classes of medications (adjusted hazard ratio: 1.16; 95% confidence interval, 0.82-1.64; not statistically significant). Patients receiving only one of the recommended classes had an intermediate risk (adjusted hazard ratio: 1.47; 95% confidence interval, 1.04-2.07; P=.03). ConclusionsPatients admitted for acute myocardial infarction with congestive heart failure criteria are still at very high risk of mortality. When receiving major recommended medications, they presented with significantly reduced mortality rates. Additional efforts should therefore be made to encourage the prescription of recommended medications in acute myocardial infarction patients with congestive heart failure.Trial registration: ClinicalTrials.gov number: NCT00673036.Full English text available from:www.revespcardiol.org

Abstract 17562: Poorer Survival with Insulin Therapy at Discharge in Diabetic Patients with Acute Myocardial Infarction: The FAST-MI Registry

The role of insulin therapy after AMI is debated. We assessed 3-year survival in survivors of AMI with diabetes, according to the prescription of insulin at discharge. All patients were included in the FAST-MI registry, a French nationwide registry of patients with AMI hospitalized in 2005 in 223 institutions. Of the 1228 diabetic patients, 467 (38%) had insulin at discharge. These were older (70±12 vs 69±12 years, p=0.004), had a higher GRACE risk score (156 ± 33 vs 147 ± 35, p&lt;0.001), higher admission glycemia (232 ± 110 vs 190 ± 85 mg/dL, p&lt;0.001), higher HbA1c (8.1 ± 1.6 vs 7.2 ± 1.4, p&lt;0.001) and longer duration of diabetes (diabetes Hx &gt;10 years: 35% vs 16.5%, p&lt;0.001). Type of MI did not differ (STEMI: 39% vs 44%, p=0.11). Fewer patients in the insulin group had coronary angiography (78% vs 88%, p&lt;0.001) or PCI (53% vs 67%, p&lt;0.001) during the hospital stay. Optimal medical therapy at discharge was prescribed in 51% vs 47% of the patients, respectively (P=0.12). Finally, other antidiabetic medications at discharge were less frequent in the insulin group (metformin: 8% vs 25%, p&lt;0.001; sulfonylureas: 9% vs 36%, p&lt;0.001; glitazones: 0.2% vs 3.4%, p&lt;0.001). Three-year survival was 66% in insulin-treated versus 80% in patients without insulin (p&lt;0.001). Subgroup analyses confirmed higher mortality in patients with insulin at discharge in both STEMI and NSTEMI patients, in those aged 75 years or less, or in those with or without PCI. Using Cox multivariate analysis (covariates: age, sex, risk factors, comorbidities, type of AMI, CAD extent, use of PCI, use of CABG, HbA1c and admission glycemia levels, duration of diabetes, in-hospital complications, and other discharge medications), the adjusted HR for 3-year death was 1.56 (1.15-2.10), p=0.004, for patients with insulin at discharge; when treatment with insulin within 48 hours of admission was added to the model, the HR was 1.40 (1.06-1.84), p&lt;0.02. Finally, in propensity score matched cohorts (n=240 in each group), HR for death at 3 years was 1.41 (1.01-1.98), p=0.04 for patients receiving insulin. Conclusion: in this real-world nationwide registry, the prescription of insulin at discharge in diabetic patients was associated with poorer long-term survival, even after extensive multivariate adjustment for confounders.

Comparison of bleeding complications and one-year survival of low molecular weight heparin versus unfractioned heparin for acute myocardial infarction in elderly patients. The FAST-MI registry

BackgroundThere are limited data on the safety and efficacy of low molecular weight heparin (LMWH) in elderly patients with acute myocardial infarction (AMI). MethodsWe aimed to compare LMWH with unfractioned heparin (UFH) in the management of AMI in elderly patients. FAST-MI is a nationwide registry carried out over a 1-month period in 2005, including consecutive patients with AMI admitted to intensive care unit <48h from symptom onset in 223 participating centers. We assessed the impact of LMWH on bleeding, the need for blood transfusion and one-year survival in elderly patients (≥75years). Results963 patients treated with heparin were included (mean age 82±5years; 51% women; 42.5% ST-elevation myocardial infarction). Major bleeding (2.4% vs. 6.1%, P=0.004) and blood transfusions (4.6% vs. 9.7%, P=0.002) were significantly less frequent with LMWH compared with the UFH, a difference that persisted after multivariate adjustment (OR=0.41, 95% CI: 0.20–0.83 and OR=0.49, 95% CI: 0.28–0.85, respectively). One-year survival and stroke and reinfarction-free survival were also significantly higher with LMWH compared with UFH (OR=0.66, 95% CI: 0.50–0.85 and OR=0.71, 95% CI: 0.56–0.91, respectively). In two cohorts of patients matched on a propensity score for getting LMWH and with similar baseline characteristics (328 patients per group), major bleeding and transfusion were significantly lower while one-year survival was significantly higher in patients receiving LMWH. ConclusionsThe present data show that in elderly patients admitted for AMI, use of LMWH is associated with less bleeding, less need for transfusion, and higher survival, compared with the use of UFH.