Article

PDF
Access to the PDF text
Advertising


Free Article !

Archives of cardiovascular diseases
Volume 103, n° 4
pages 207-214 (avril 2010)
Doi : 10.1016/j.acvd.2010.02.002
Received : 7 August 2009 ;  accepted : 17 February 2010
Impact of polyvascular disease on baseline characteristics, management and mortality in acute myocardial infarction. The Alliance project
Impact de l’atteinte vasculaire extracoronarienne sur les caractéristiques, la prise en charge et la mortalité des patients admis pour infarctus du myocarde à partir des données du registre Alliance
 

Anouk Meizels a, David Messika Zeitoun a, i, Vincent Bataille b, Jean-Pierre Cambou c, Jean-Philippe Collet d, Yves Cottin e, Jean-Jacques Dujardin f, Patrick Goldstein g, Nicolas Danchin h, Daniel Thomas c, Phillipe Gabriel Steg a, , i

The ALLIANCE investigators on behalf of the working group on Epidemiology of the French Society of Cardiology

a Inserm U-698 Recherche clinique en athérothrombose, service de cardiologie, centre hospitalier Bichat-Claude-Bernard, Assistance publique–Hôpitaux de Paris, université Paris VII Denis-Diderot, 46, rue Henri-Huchard, 75877 Paris cedex 18, France 
b ADIMEP, CHU de Toulouse, Toulouse, France 
c Service de cardiologie, CHU de Rangueil, 31059 Toulouse, France 
d Service de cardiologie, hôpital Pitié-Salpêtrière, 47–83, boulevard de l’Hôpital, 75013 Paris, France 
e Service de cardiologie, CHU Bocage, 21000 Dijon, France 
f Service de cardiologie, CHU Douais, route de Cambrai, BP 740, 59507 Douais cedex, France 
g CHRU de Lille, 59000 Lille, France 
h Service de cardiologie, hôpital européen Georges-Pompidou, 20, rue Leblanc, 75015 Paris, France 
i Inserm, U698, recherche clinique en athérothrombose, University Paris-7 Denis-Diderot, 46, rue Henry-Huchard, 75018 Paris, France 

Corresponding author. Fax: +33 1 40 25 88 65.
Summary
Background

A substantial number of patients with acute myocardial infarction (AMI) have polyvascular disease (PolyVD), defined as cerebrovascular disease (CVD), peripheral arterial disease (PAD) or both.

Aim

To investigate the impact of PolyVD on baseline characteristics, management and outcomes.

Methods

The Alliance project is a multicentre, cross-sectional database of patients with myocardial infarction throughout France from 2000 to 2005. A pooled analysis of individual patient data was performed by aggregating data from five registries, representing 9783 patients hospitalized for acute coronary syndromes. Data were collected on history of PAD and CVD and correlated to baseline characteristics, management and hospital outcomes.

Results

Eight thousand nine hundred and four patients had full datasets for this analysis (13% with a history of CVD or PAD, 87% without). Patients with PolyVD were older (72 vs 65 years, p <0.0001), had a more frequent history of AMI (26% vs 15%, p <0.0001), percutaneous coronary intervention (PCI), coronary artery bypass graft (CABG), renal insufficiency (12% vs 3%, p <0.0001) and consistently more risk factors for atherosclerosis (hypertension, dyslipidaemia, smoking, diabetes), but less frequently a body mass index>30kg/m2 (14.0% vs 20.1%, p <0.0001) compared to patients with coronary artery disease (CAD) alone. Killip class, left-ventricular ejection fraction and GUSTO risk score were all worse among patients with PolyVD. Management of patients with PolyVD was less aggressive (with later admission and less frequent use of in-hospital angiography or evidence-based therapies at discharge). Mortality of patients with PolyVD was consistently higher than in those with CAD alone, regardless of age. Multivariable analysis, adjusting for age, showed that both PAD (odds ratio 1.36 95% confidence interval 1.03–1.79) and history of CVD (odds ratio 1.74, 95% confidence interval 1.27–2.40) were independent predictors of hospital mortality relative to patients with CAD only.

Conclusion

Patients with PolyVD represented a substantial group among AMI patients, at particularly high risk of death, yet were managed less aggressively than patients with CAD alone. This was associated with markedly higher in-hospital mortality. Further research is warranted to design and test strategies to decrease mortality in this high-risk subset.

The full text of this article is available in PDF format.
Résumé
Introduction

Une proportion significative de patients hospitalisés pour infarctus du myocarde (IDM) présente une atteinte vasculaire extracoronarienne associée, définie par un accident vasculaire cérébral (AVC), une atteinte artérielle périphérique (AAP) ou les deux. L’impact de cette atteinte polyvasculaire sur les caractéristiques de ces patients, leur prise en charge hospitalière et leur pronostic est mal connu.

Méthodes

Le registre Alliance est une base de données multicentrique de patients admis pour un IDM en France de 2000 à 2005. Le recueil des données a été réalisé en utilisant cinq registres représentant 9783 patients hospitalisés pour syndrome coronarien aigu entre 2000 et 2005. Les antécédents d’AVC ou d’AAP ont été colligés et corrélés aux caractéristiques cliniques, à la prise en charge médicale et interventionnelle et à la mortalité hospitalière.

Résultats

L’ensemble des données a pu être recueilli chez 8904 patients. Parmi eux, 13 % avait une atteinte polyvasculaire, alors que 87 % n’avaient pas d’antécédent d’AVC et d’AAP. Les patients avec une atteinte vasculaire extracoronarienne étaient plus âgés (72 versus 65 ans, p <0,0001), avaient plus souvent des antécédents coronariens : antecedent d’IDM (26,1 versus 14,7 %, p <0,0001), d’angioplastie, ou de pontage aortocoronarien, et d’insuffisance rénale (11,9 % versus 2,5 %, p <0,0001). La prévalence des facteurs de risque cardiovasculaire (hypertension, dyslipidemie, tabac, diabète) était globalement plus importante, sauf pour l’obésité (BMI>30) (14,0 versus 20,1 %, p <0,0001). De même, la classe Killip était plus élevée, la fraction d’éjection plus basse et le score Gusto plus sévère. Leur prise en charge était moins agressive avec un délai entre le début des symptômes et l’admission plus long, moins de coronarographie et d’angioplastie (48 % versus 62 %, p <0,0001), et une moindre prescription des quatre traitements recommandés par les guidelines (antiagrégants plaquettaires, bêtabloquants, statines et IEC). La mortalité hospitalière était plus élevée (12 % versus 6 %, p <0,0001) et augmentait avec l’âge. Après ajustement pour l’âge, la présence d’antécédents d’AAP (OR : 1,36, 95 % CI : 1,03–1,79) ou d’AVC (OR 1,74, 95 % CI : 1,27–2,40) était un marqueur prédictif indépendant de mortalité hospitalière (OR 1,52 [1,23–1,88], p <0,0001).

Conclusion

L’atteinte vasculaire extracoronaire est fréquente chez les patients hospitalisés pour IDM et identifie un sous-groupe à haut risque avec des caractéristiques plus sévères, une mortalité accrue mais une prise en charge moins agressive et un traitement médical moins souvent optimal. Des études complémentaires sont nécessaires pour évaluer l’impact d’une stratégie plus intensive sur la mortalité dans ce sous-groupe à haut risque.

The full text of this article is available in PDF format.

Keywords : Acute myocardial infarction, Cerebrovascular disease, Coronary artery disease, Polyvascular disease

Mots clés : Infarctus du myocarde, Atteinte vasculaire extracoronarienne, Mortalité, Facteurs de risque cardiovasculaire


Background

Cardiovascular disease, due to cerebrovascular disease (CVD), peripheral arterial disease (PAD) or coronary artery disease (CAD), is the leading cause of mortality and morbidity in industrialized countries [1]. Atherothrombosis is a common (but not exclusive) underlying cause of these three diseases. Therefore, CVD, PAD and CAD are often different locations of a similar underlying disease, share similar risk factors (albeit with a different relative weight for each of the locations) and frequently coexist [2]. In the REduction of Atherothrombosis for Continued Health (REACH) Registry, there was major overlap between the various locations of the symptomatic location of the disease [3], and mortality and morbidity increased with the extent of atherosclerotic burden (i.e., number of arterial beds affected) [4].

Major advances have been made in the prevention, diagnosis and treatment of CAD. Randomized trials provide robust evidence that pharmacological and interventional therapies improve the outcome of patients with acute coronary syndromes (ACS) and have led to changes in clinical practice and guidelines [5, 6, 7, 8]. Observational data from the Global Registry of Acute Coronary Events (GRACE) [9] have shown that in routine practice, improvement in the management of patients with ACS is associated with a significant rate reduction in heart failure, acute myocardial infarction (AMI) and death. In contrast, patients with non-coronary atherosclerotic vascular disease, and especially PAD, are regarded as particularly high-risk, yet are often underdiagnosed and undertreated [10, 11, 12]. For example, patients with PAD, compared to those with CAD, were less likely to be treated with aspirin or lipid-lowering therapy if they were hypercholesterolaemic [13].

Acute myocardial infarction is the most frequent and potentially fatal event in patients with cardiovascular disease, and the impact of the association of PAD or CVD on the management and outcome of patients hospitalized for AMI has not been fully evaluated. We hypothesized that a history of PAD or CVD may affect clinical presentation, management and outcome. We therefore used data from the Alliance consortium of AMI to compare baseline characteristics, management and in-hospital outcomes of patients with AMI alone with those of patients with associated CVD or/and PAD.

Methods
Study design

The Alliance project is a multicentre, cross-sectional database of 9783 patients admitted for AMI throughout France from 2000 to 2005. The purpose of the project is to provide aggregate data and test hypotheses regarding AMI in France. It is a pooled analysis of data from five registries: FACT (2003 nationwide survey with 2517 patients) [14], USIC (2000 nationwide survey with 2315 patients) [15, 16], RICO (2000–2005 continuous registry department of Burgondy with 4057 patients) [17], Paris (2000–2005 continuous registry of University Hospital Pitié-Salpétrière Paris with 652 patients) [18] and eParis (2000–2005 continuous registry with 242 patients). All patients gave informed consent for participation in the survey and follow-up.

Definitions

Acute myocardial infarction was defined as an increase in one cardiac biochemical marker of necrosis (troponin I or T or creatine phosphokinase [CPK] MB) at least twice the upper normal limit [19] and at least one of the following criteria: chest pain lasting for at least 20minutes not relieved by nitrates, electrocardiographic changes on at least two contiguous leads with persisting ST elevation or depression ≥ 0.1mV and/or pathological Q waves. Patients were classified into three categories: ST-segment elevation myocardial infarction (STEMI), non-ST-segment elevation myocardial infarction (NSTEMI) [20] or undetermined electrocardiographic pattern (left bundle-branch block or paced rhythm).

Vascular disease

Diagnosis of PAD was made on the basis of the presence of one of the following: history of claudication, peripheral vascular surgery, vascular angioplasty or amputation or documented abdominal aortic aneurysm. The diagnosis of CVD was based on a history of transient ischaemic attack (TIA), stoke, carotid endarterectomy or carotid stent implantation. TIA was defined as a history of loss of neurological function caused by ischaemia that was abrupt in onset but with complete return of function within 24hours. Stroke was defined as a loss of neurological function caused by an ischaemic event, with residual symptoms.

Data collection

Data regarding patient demographics, risk factors, medical history, clinical presentation, prehospital delay, in-hospital management and in-hospital mortality were collected. Polyvascular disease (PolyVD) was defined as patients with CVD, PAD or both. Items used for the pooled analysis were defined in a similar manner across registries, using simple clinical definitions.

Statistical analysis

Data are presented as number of patients (per cent) or mean±standard deviation (SD). Differences in baseline characteristics, hospital management and mortality between patients with and without PolyVD were assessed by use of the t test or the χ 2-test as appropriate. Final regression models were adjusted for age divided into three categories (< 60; 60–75; > 75 years) or as a continuous variable. A p value<0.05 was considered significant.

Results
Baseline characteristics

Among the 9783 patients with AMI enrolled in the five registries between 2000 and 2005, 91% (n =8904) had complete datasets and constituted our study population. Clinical characteristics are summarized in Table 1. Briefly, the mean age was 66±14 years, 72% were men and the prevalence of cardiovascular risk factors was high.

Among the 8904 patients, 4% (n =356) patients had a history of stroke or TIA (CVD), 8% (n =712) had a history of PAD and 1% (n =89) had a history of both CVD and PAD. Therefore, 13% (n =1161) of patients had a history of PolyVD (Figure 1). Patients with a history of PolyVD were older (p <0.0001), had consistently more cardiovascular risk factors (all p <0.005), but were less frequently obese (body mass index ≥ 30kg/m2) (p <0.0001) (Table 1). They were also more likely to have a history of CAD (p <0.0001) or renal insufficiency (p <0.0001).



Figure 1


Figure 1. 

Symptomatic polyvascular disease in acute myocardial infarction: The Alliance consortium (n =9783). CAD: coronary artery disease; CVD: cerebrovascular disease; PAD: peripheral arterial disease.

Zoom

Clinical presentation

Among the 8904 patients analyzed, 70% (n =6224) presented with STEMI, 25% (n =2244) with NSTEMI, and 5% (n =436) with an undetermined electrocardiographic pattern.

Patients with prior PolyVD were less likely to present with STEMI (p <0.0001) and more likely to have NSTEMI (p <0.0001) or an undetermined electrocardiographic pattern (p <0.0001) than patients without PolyVD. They also presented with a higher Killip class and a lower ejection fraction (both p <0.0001) and the delay from symptom onset to admission was longer (p <0.0001) than that of patients without PolyVD (Table 2).

In-hospital mortality

The overall in-hospital mortality was 6.5% (n =577), 7.2% (n =506) in patients with STEMI, 4.3% (n =96) in NSTEMI and 12.5% (n =57) in patients with an undetermined electrocardiographic pattern). A two-fold increase in hospital mortality was observed in patients with PolyVD (p <0.001) compared to patients without PolyVD (Figure 2A). Mortality was highest in AMI patients with prior CVD or both prior CVD and PAD (14% [n =365]) and 13% (n =77), respectively, vs. 9.8% (n =703) in patients with AMI and PAD and 5.7% (n =7739) in patients without PolyVD, (p <0.001) (Figure 2B).



Figure 2


Figure 2. 

In-hospital mortality in patients with acute myocardial infarction according to the (A) presence or absence of polyvascular disease (PolyVD); (B) disease location (coronary artery disease [CAD], cerebrovascular disease [CVD], peripheral arterial disease [PAD]); and (C) age group.

Zoom

Mortality increased sharply with age, from 1.7% in patients aged<60 years to 4.6% between 60 and 75 years, and 11.8% after 75 years. Even though patients with PolyVD were on average older than patients with CAD alone, mortality remained higher across all age categories (Figure 2C) and remained higher after adjustment for age (odds ratio [OR] 1.52, 95% confidence interval [CI] 1.23–1.88, p <0.001) (Table 3). Similar results were observed after additional adjustment for the five registries (OR 1.50, 95% CI 1.23–1.82, p <0.001).

In-hospital management
Procedures

During the index hospitalization, 84% (n =7398) of patients underwent coronary angiography, 59% (n =5244) percutaneous coronary intervention (PCI), 23% (n =2048) primary PCI and 72% (n =836) coronary artery bypass graft (CABG) surgery. Compared to patients without PolyVD, patients with prior PolyVD less frequently underwent coronary angiography (72% [n =839] vs 85% [n =6582], p <0.0001) or PCI (48% [n =560] vs 62% [n =4470], p <0.0001), whereas the rate of CABG was similar (7% [n =85] vs 7% [n =542], p =0.75), especially in patients with PAD (9%) (Table 2). Rates of primary PCI did differ between groups (p 0.0001) (Figure 3).



Figure 3


Figure 3. 

In-hospital revascularization in patients with acute myocardial infarction according to the presence of peripheral arterial disease (PAD), cerebrovascular disease (CVD), both, or coronary artery disease (CAD) alone. CABG: coronary artery bypass graft; PCI: percutaneous coronary intervention.

Zoom

Medical therapy

Among the 8327 patients discharged alive, 65% (n =5373) received statins, 71% (n =5891) beta-blockers, 56% (n =4696) an angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) and 84% (n =7012) antiplatelet therapy. Compared to patients with CAD alone, patients with PolyVD were less frequently prescribed statins (60% vs 65%, p =0.003) and beta-blockers (64% vs 72%, p <0.0001), but more frequently received ACE inhibitors or ARBs (61% vs 56%, p <0.002). The rate of antiplatelet therapy was similar in both groups (85% vs 82%, p =0.09).

Discussion

Among patients admitted to hospitals in France for AMI, the presence of prior CVD or PAD was common, was associated with more cardiovascular risk factors and a more severe clinical presentation. Patients with PolyVD less often received guideline-recommended medications, underwent fewer coronary percutaneous revascularization procedures and had a higher in-hospital morbidity compared to patients with CAD alone.

A common and high-risk subgroup

In the present study, 13% of patients admitted for AMI had symptomatic PolyVD (rising to almost 20% in patients aged 75 years and older), confirming the strong association between PAD, CVD and CAD. The effect of PAD on hospital outcome in patients admitted for ACS was evaluated in the GRACE registry [21]. Our study corroborates and extends previous observations to all patients with PolyVD, including PAD and CVD, using the resources of the Alliance project. Patients with prior PolyVD admitted for AMI had worse baseline characteristics (they were older, more likely to have renal insufficiency and a higher prevalence of cardiovascular risk factors) and had higher in-hospital mortality. This increased mortality rate was observed in all age categories and PolyVD was a strong and independent predictor of in-hospital mortality. Thus, our data show that in patients admitted for AMI, the extent of the atherosclerotic burden is associated with worse in-hospital mortality. An important clinical implication of the present study is that a history of symptomatic PAD or CVD, which can be simply assessed by physicians in a few minutes, is a strong prognostic factor.

Less-aggressive management

Despite the high prevalence of PolyVD and its strong association with cardiovascular morbidity and mortality, PolyVD has received relatively little attention in the context of AMI. Cardiovascular risk factors are less-often controlled in patients with PAD and guideline-recommended medications (antiplatelet therapy, beta-blockers, statins and ACE/ARBs [5, 6, 7, 8, 10, 22]) are less often used despite the obvious benefits of these guideline-recommended medications on outcomes [12, 23].

The present study documents less-aggressive management of patients with prior PolyVD admitted for AMI, with delayed times to admission, a lower procedural rate (angiography), and less frequent use of guideline-recommended medications at discharge. The rates of primary PCI were similar regardless of the presence or absence of PolyVD, suggesting that the more conservative management of polyVD patients was related mostly to patients with NSTEMI. It is not clear why higher risk patients with PolyVD underwent fewer coronary procedures. Some physicians may decide to withhold coronary angiography in this older population, who have more frequent comorbidities including renal insufficiency.

The underuse of guideline-recommended medications is a missed opportunity in patients eligible for these drugs, since if they are not introduced during the index hospitalization, they are rarely initiated afterwards. Only 41% of patients with PolyVD received the four guideline-recommended medications. However, in the present study, we could not investigate whether the differences in medication use between patients with and without PolyVD were or were not appropriate. It is possible that beta-blockers were prescribed less frequently because patients with PolyVD had more severe heart failure or because of a fear of potential adverse effects in patients with PAD or in patients with more frequent history of smoking. The lower use of statins in patients with PolyVD is less easy to understand, as multiple studies have demonstrated the consistent effectiveness of statin therapy in patients presenting with AMI regardless of their clinical profile.

Thus, despite a higher risk profile and a greater incidence of comorbidities, patients with a history of PAD or CVD were less likely to receive effective cardiac medications and interventional procedures. Even if it would appear intuitive, whether these treatment disparities contributed to the observed difference in hospital mortality is not entirely clear and cannot be inferred from the present data. Nevertheless, guideline-recommended medications should be strongly recommended in this high-risk subgroup [24]. In the GRACE registry, improvement in the clinical outcome resulting from changes in pharmacological and procedural care of patients with AMI was independent of the risk status of the study population [9], and use of guideline-recommended medications was associated with improved outcome in all subgroups [25]. In addition, use of a combination of guideline-recommend medications was associated with lower 6-month mortality, with an incremental and synergistic effect [24]. These findings suggest a need for further evaluation of treatment decisions in patients with PolyVD presenting with an AMI and demonstrate considerable opportunity to improve the outcomes of these high-risk patients. Future clinical trials will evaluate the impact of an aggressive atherosclerosis risk-factor management and strategy on outcomes in patients with PolyVD admitted for AMI.

Limitations

The Alliance project is an observational study gathering data from five different registries and is therefore subject to inherent limitations particularly related to the potential heterogeneity between studies [26]. However, definitions were homogeneous and endpoints (medications, coronary intervention or total death) were unambiguous and easy to ascertain. Almost all (91%) of the patients in these five studies contributed data to the pooled analysis, therefore it is unlikely that patient selection created bias. Furthermore, an excess mortality in patients with PolyVD was observed in each registry (ORs ranging from 1.21 to 1.85) and the excess mortality in PolyVD patients was also observed after adjustment for the type of registry. Another concern relates to the fact that the use of additional key therapies such as clopidogrel or glycoprotein IIb/IIIa inhibitors was not recorded in each registry and therefore could not be analysed, yet their underuse may have contributed to the higher mortality of PolyVD patients. Third, PolyVD was self-reported. This may lead to under-diagnosis of PAD or CVD, and whether our findings can be extrapolated to patients with asymptomatic PAD or CVD deserves further investigation. Finally, the present study did not evaluate long-term morbidity and mortality.

Conclusion

Polyvascular disease is frequent among patients admitted for AMI and is an easy and simple predictor of outcome. Despite a more severe clinical presentation and a worst outcome, patients with PolyVD received fewer guideline-recommended medications and had fewer coronary procedures performed, which may explain, at least partially, their higher in-hospital mortality. These results demonstrate considerable opportunity to improve the outcome of these high-risk patients. Flagging patients with known PolyVD early after admission and early recognition of their intrinsic poor prognosis may help clinicians to ensure that they receive appropriate care while in hospital and are prescribed evidence-based medications at discharge.

Conflict of interest statement

None.


Acknowledgements

We are indebted to sanofi-aventis and Bristol-Myers-Squibb, who supported the FACT and USIC registries; to URCAM Burgondy, ARH Burgondy and Burgondy cardiology association, which supported the RICO registry; and to the personnel who participated in the set up and analysis of each of the studies.

Dr Meizels was supported by a grant from the French federation of Cardiology. Dr Messika-Zeitoun was supported by a contrat d’interface Inserm.

References

Chabot J.M. A report from the World Health Organization Rev Prat 2002 ;  52 : 2155-2156
Ohman E.M., Bhatt D.L., Steg P.G., and al. The REduction of Atherothrombosis for Continued Health (REACH) Registry: an international, prospective, observational investigation in subjects at risk for atherothrombotic events-study design Am Heart J 2006 ;  151 (786) : e1-e10
Bhatt D.L., Steg P.G., Ohman E.M., and al. International prevalence, recognition, and treatment of cardiovascular risk factors in outpatients with atherothrombosis JAMA 2006 ;  295 : 180-189 [cross-ref]
Steg P.G., Bhatt D.L., Wilson P.W., and al. One-year cardiovascular event rates in outpatients with atherothrombosis JAMA 2007 ;  297 : 1197-1206 [cross-ref]
Antman E.M., Anbe D.T., Armstrong P.W., and al. ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction--executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1999 Guidelines for the Management of Patients With Acute Myocardial Infarction) Circulation 2004 ;  110 : 588-636 [cross-ref]
Antman E.M., Anbe D.T., Armstrong P.W., and al. ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Revise the 1999 Guidelines for the Management of Patients with Acute Myocardial Infarction) Circulation 2004 ;  110 : e82-292
Bertrand M.E., Simoons M.L., Fox K.A., and al. Management of acute coronary syndromes in patients presenting without persistent ST-segment elevation. The Task Force on the management of acute coronary syndromes of the European Society of Cardiology Eur Heart J 2002 ;  23 : 1809-1840 [cross-ref]
Braunwald E., Antman E.M., Beasley J.W., and al. ACC/AHA 2002 guideline update for the management of patients with unstable angina and non-ST-segment elevation myocardial infarction--summary article: a report of the American College of Cardiology/American Heart Association task force on practice guidelines (Committee on the Management of Patients With Unstable Angina) J Am Coll Cardiol 2002 ;  40 : 1366-1374 [cross-ref]
Fox K.A., Steg P.G., Eagle K.A., and al. Decline in rates of death and heart failure in acute coronary syndromes, 1999-2006 JAMA 2007 ;  297 : 1892-1900 [cross-ref]
Hirsch A.T., Haskal Z.J., Hertzer N.R., and al. ACC/AHA 2005 Practice Guidelines for the management of patients with peripheral arterial disease (lower extremity, renal, mesenteric, and abdominal aortic): a collaborative report from the American Association for Vascular Surgery/Society for Vascular Surgery, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, Society of Interventional Radiology, and the ACC/AHA Task Force on Practice Guidelines (Writing Committee to Develop Guidelines for the Management of Patients With Peripheral Arterial Disease): endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation; National Heart, Lung, and Blood Institute; Society for Vascular Nursing; TransAtlantic Inter-Society Consensus; and Vascular Disease Foundation Circulation 2006 ;  113 : e463-654
Belch J.J., Topol E.J., Agnelli G., and al. Critical issues in peripheral arterial disease detection and management: a call to action Arch Intern Med 2003 ;  163 : 884-892 [cross-ref]
Cacoub P., Cambou J.P., Kownator S., and al. Prevalence of peripheral arterial disease in high-risk patients using ankle-brachial index in general practice: a cross-sectional study Int J Clin Pract 2009 ;  63 : 63-70 [cross-ref]
McDermott M.M., Mehta S., Ahn H., and al. Atherosclerotic risk factors are less intensively treated in patients with peripheral arterial disease than in patients with coronary artery disease J Gen Intern Med 1997 ;  12 : 209-215 [cross-ref]
Dujardin J.J., Steg P.G., Puel J., and al. FACT: French national registry of acute coronary syndromes. Specific study of French general hospital centers Ann Cardiol Angeiol (Paris) 2003 ;  52 : 337-343 [inter-ref]
Hanania G., Cambou J.P., Gueret P., and al. 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 Heart 2004 ;  90 : 1404-1410 [cross-ref]
Aboyans V., Cambou J.P., Hanania G., and al. Clinical and therapeutic specificities of myocardial infarction in patients with peripheral arterial disease: the USIC 2000 registry Ann Cardiol Angeiol (Paris) 2005 ;  54 : 241-249 [inter-ref]
Zeller M., Ravisy J., Beer J.C., and al. Risk stratification in pre-hospital management of myocardial infarction with ST elevation: value of a risk score profile Arch Mal Coeur Vaiss 2005 ;  98 : 1130-1136
Collet J.P., Montalescot G., Vicaut E., and al. Acute release of plasminogen activator inhibitor-1 in ST-segment elevation myocardial infarction predicts mortality Circulation 2003 ;  108 : 391-394 [cross-ref]
Alpert J.S., Thygesen K., Antman E., and al. Myocardial infarction redefined--a consensus document of The Joint European Society of Cardiology/American College of Cardiology Committee for the redefinition of myocardial infarction J Am Coll Cardiol 2000 ;  36 : 959-969
Steg P.G., Goldberg R.J., Gore J.M., and al. Baseline characteristics, management practices, and in-hospital outcomes of patients hospitalized with acute coronary syndromes in the Global Registry of Acute Coronary Events (GRACE) Am J Cardiol 2002 ;  90 : 358-363 [cross-ref]
Froehlich J.B., Mukherjee D., Avezum A., and al. Association of peripheral artery disease with treatment and outcomes in acute coronary syndromes. The Global Registry of Acute Coronary Events (GRACE) Am Heart J 2006 ;  151 : 1130-1135
Hirsch A.T., Haskal Z.J., Hertzer N.R., and al. ACC/AHA 2005 guidelines for the management of patients with peripheral arterial disease (lower extremity, renal, mesenteric, and abdominal aortic): executive summary a collaborative report from the American Association for Vascular Surgery/Society for Vascular Surgery, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, Society of Interventional Radiology, and the ACC/AHA Task Force on Practice Guidelines (Writing Committee to Develop Guidelines for the Management of Patients With Peripheral Arterial Disease) endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation; National Heart, Lung, and Blood Institute; Society for Vascular Nursing; TransAtlantic Inter-Society Consensus; and Vascular Disease Foundation J Am Coll Cardiol 2006 ;  47 : 1239-1312 [cross-ref]
Mukherjee D., Lingam P., Chetcuti S., and al. Missed opportunities to treat atherosclerosis in patients undergoing peripheral vascular interventions: insights from the University of Michigan Peripheral Vascular Disease Quality Improvement Initiative (PVD-QI2) Circulation 2002 ;  106 : 1909-1912 [cross-ref]
Mukherjee D., Fang J., Chetcuti S., and al. Impact of combination evidence-based medical therapy on mortality in patients with acute coronary syndromes Circulation 2004 ;  109 : 745-749 [cross-ref]
Mukherjee D., Eagle K.A., Kline-Rogers E., and al. Impact of prior peripheral arterial disease and stroke on outcomes of acute coronary syndromes and effect of evidence-based therapies (from the Global Registry of Acute Coronary Events) Am J Cardiol 2007 ;  100 : 1-6 [cross-ref]
Simmonds M.C., Higgins J.P., Stewart L.A., and al. Meta-analysis of individual patient data from randomized trials: a review of methods used in practice Clin Trials 2005 ;  2 : 209-217 [cross-ref]



© 2010  Published by Elsevier Masson SAS.
EM-CONSULTE.COM is registrered at the CNIL, déclaration n° 1286925.
As per the Law relating to information storage and personal integrity, you have the right to oppose (art 26 of that law), access (art 34 of that law) and rectify (art 36 of that law) your personal data. You may thus request that your data, should it be inaccurate, incomplete, unclear, outdated, not be used or stored, be corrected, clarified, updated or deleted.
Personal information regarding our website's visitors, including their identity, is confidential.
The owners of this website hereby guarantee to respect the legal confidentiality conditions, applicable in France, and not to disclose this data to third parties.
Close
Article Outline