1. 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

3. Nord Haute-Garonne Haute-Savoie Côte-d’Or Essonne Popul. millions Area km 2 Density inha/km 2 NORD 2,55 743447 Essonne 1,21 804668 Hte Garonne 1,26 309193 Hte Savoie 0,74 388163 Côte d’Or 0,58 76360 # 6

4. Côte-d’Or : 29 Haute-Garonne : 39 Nord : 57 Haute-Savoie : 37 Essonne : 38 Almost 3/4 of males : 72,5 % male Demographic characteristics 200 patients analysed

5. – 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

6. – 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 %

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 1 st medical contact in less than 50 % of cases

8. Patients without reperfusion : older Half are female ¼ are employed Revascularisation modes FibrinolysisPrimary PCIno reperfusionp Population Age Female (%) Occupation (%) Employed Unemployed Retired 22 % 63 ± 13 23 % 44 5,1 51,3 64 % 62 ± 13 24 % 41 8,1 50,5 14 % 70 ± 12 50 % 22 4,3 73,9 < 0,001 < 0,01 < 0,02 0,32

9. Widimsky P et al, Eur Heart J 2010; 31:943-57. Primary PCI Thrombolysis No reperfusion France 64 22 14

10. 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 1 er call Admission P PCI 20 min 33 min 54 min 43 min 97 min sympto m onset FMC

11. Symptom onset Patients referred to peripheral centres Admission to the cath lab P PCI 163 min 227 min 204 min Mean delay was more than double FMC

12. Effects of numbers of actors 4,2 5,5 9,7 % hospital mortality Nr of actors

14. 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

15. FAST-MI 2010  213 centres  Inclusion from October 2010  4169 patients included  3079 patients included during the first month  213 centres  Inclusion from October 2010  4169 patients included  3079 patients included during the first month

16. Proportion of STEMI patients from 1995 to 2010 Generalised use of troponin measurement

17. Admission diagnosis: STEMI vs NSTEMI

18. First place of arrival STEMI NSTEMI 38+11.5% call SAMU first 21% call their GP first 19% go to ER 29+8% call SAMU first 27% call their GP first 19% go to ER

20. Increased % of younger women

21. Time to first call in STEMI patients % of patients calling ≤60 min from onset

22. Use of the SAMU/firebrigade in STEMI Use of the SAMU/ FB in patients with STEMI 20052010

23. Reperfusion therapy in STEMI

24. STEMI: early mortality according to use and type of reperfusion therapy 2.1 2.6 - 48 %- 74 %- 70 %

25. 30-day mortality: STEMI & NSTEMI 5 ?

27. 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

28. Genetic determinants of clopidogrel response and clinical events in FAST-MI 2005 Simon et al. NEJM 2009 FAST-MI registry 2,208 patients with AMI, followed for one year Number of CYP2C19 loss-of-function alleles

29. Early prescription of statins is associated with lower risk of developing acute AF Danchin et al. Heart 2010 % of patients developing AF

30. LMWH vs UFH in elderly patients Puymirat et al. Int J Cardiol 2012 Survival in propensity score-matched cohorts

31. 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)

32. 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.

33. 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.