Effect of time to treatment and age on one year mortality in acute STEMI: difference between thrombolysis and primary percutaneous coronary intervention.

CONTEXT: Although thrombolysis (THL) and primary percutaneous coronary intervention (PPCI) are two validated options in reperfusion algorithms for ST-elevation myocardial infarction (STEMI), recent papers seems to show that PPCI could be the best therapeutic option irrespective of the time to treatment (TT) and of the cardiovascular risk profile of the patient. The impact of TT and age on reperfusion strategies requires elucidation. The aim of this study was to analyze the effect of time to treatment and age on the 1-year mortality of patients presenting with STEMI, for each reperfusion strategy. MATERIALS AND METHODS: The study population consisted in 794 patients directly admitted to the cardiological intensive care unit for STEMI < or =12 hours. The relationship between TT and 1-year mortality was studied using logistic regression models. The models were implemented on the overall population and on 3 different age groups: [<65 years]; [> or =65 and <75 years]; [> or =75 years] for patients undergoing THL (n=299) and for patients undergoing PPCI (n=495). There was no significant between-group difference in all-cause 1-year mortality for the patients [<65 years] and those [> or =65 and <75 years]. In contrast, the 1-year mortality was significantly higher in the patients [> or =75 years] undergoing THL (51.4 vs. 15.3%; p<0.001). The analysis of the curves of mortality suggests that 1- year mortality of patients with STEMI depend not only on reperfusion strategy but so on the time to treatment and on the age of the patients. CONCLUSION: In STEMI, on a 1-year mortality criteria, PPCI is not always upper than THL, particularly for patients<65 years treated within the first two hours after symptoms onset. TT and age affects the results of the reperfusion strategies and must be still incorporated in the reperfusion algorithms of STEMI.

[Effects of delay in onset of revascularisation strategies in the acute phase of myocardial infarction]. / Place du délai de prise en charge dans la stratégie de revascularisation à la phase aiguë de l'infarctus du myocarde. Données issues de la vie réelle.

BACKGROUND: thrombolysis (THL) and primary percutaneous coronary intervention (PCI) are therapeutic options in acute myocardial infarction (MI). These strategies have similar efficiency, particularly in the early phase. However, in these randomized studies, different times to treatment (TT) threshold are recognized as discriminant. OBJECTIVES: to validate, on a one year mortality criteria the best TT threshold in the real life. METHODS: 794 patients, admitted directly in our institution with a Ml< or =12 hours; 299 were treated by THL and 495 by PCI. The primary end-point was 1-year mortality according to TT and strategy of revascularization. Three TT thresholds were tested (120, 150 and 180 min) to define the best strategy of revascularisation. RESULTS: only the 150 min TT threshold showed a significant difference between the two strategies. If TT was less than 150 min, relative risk of 1-year mortality was 1.36 (p=0.62) for patients treated by THL compared to those treated with PCI. By contrast, the relative risk of one year mortality was 1.95 if Tr was greater than 150 min (p=0.02). CONCLUSION: TT is a key factor to define the best strategy of reperfusion. The critical threshold seems to be at 150 min. THL should be considered as a therapeutic choice only if administered within the first 150 min. After this delay, primary PCI should be preferred.

[Angioplasty at the bifurcation of the anterior interventricular artery and diagonal artery]. / Angioplastie de la bifurcation de l'artère interventriculaire antérieure et de l'artère diagonale.

UNLABELLED: The IVA/diagonal coronary bifurcation is a high risk area for atheromatous disease. Major technical and strategic risks make the treatment of these lesions a real "challenge" for the interventional cardiologist: angioplasty-stenting and surgery are in direct competition. OBJECTIVES: the aim of this study was to determine the significance of interventional techniques in treating the IVA/diagonal bifurcation, drawing on the experiences of a cardiological haemodynamic laboratory and comparing these results with those obtained with the reference technique, represented by aorto-coronary bypass with the internal mammary artery. METHODS: this was a monocentric retrospective study of a series of 133 patients treated with angioplasty-stenting between January 1997 and December 2002 for a new IVA/Dg bifurcation lesion. Patients admitted for myocardial infarction were excluded. RESULTS: no matter which angioplasty revascularisation technique was used, the angiographic success rate was 95% with 3% occlusions of the diagonal artery. At six months, 72% of patients were asymptomatic, the rate of treated lesion revascularisation (TLR) was 21.9%. At one year 68.8% of patients were asymptomatic, and the TLR was 24.2%. The technique evolved during the six years, especially with the expansion of the radial approach and increasingly frequent use of the "kissing balloon"; at one year the TLR and the rate of major cardiac events was 31% in 1997 and 15% in 2002. CONCLUSIONS: angioplasty-stenting in this at-risk region is thus favourable, and gives results comparable with those of internal mammary/IVA bypass, save on the TLR. However, the development of stents "pre-formed" for the bifurcation and especially "active" endoprostheses could represent a solution to the delicate problem of restenosis.

[Comparison of coronary angiography by the left radial and right femoral approach with 4 French catheters]. / Comparaison de la coronarographie par voie radiale gauche et fémorale droite avec des sondes 4 french.

The radial arterial approach has been shown to be valuable for coronary angioplasty. The aim of this study was to evaluate the use of the left radial and right femoral approaches for diagnostic coronary angiography. The authors performed a prospective non-randomised series of consecutive diagnostic coronary angiogrammes with small calibre (4 french) catheters by the left radial (100 patients) and right femoral (100 patients) arteries. The feasibility, results and complications were compared. The study showed that diagnostic coronary angiography with 4 F catheters is feasible with a high success rate, both from the left radial (99%) and right femoral (100%) approaches (NS). The duration of the procedure tends to be longer when the radial approach is used (19.2 +/- 1.3 min) than by the femoral artery (16.3 +/- 1.1 min) (p = 0.06). The duration of irradiation is longer with the radial approach (6.7 +/- 1.2 vs 4.9 +/- 0.9 min) (p = 0.0001). Local complications are minor by either approach (N = 5 vs N = 6 patients; p = NS), and there were no major complications. The tolerance of the procedure was not as good when the radial artery was used (N = 5) compared with the femoral artery (N = 1 patient) because of arterial spasm when the catheters were changed. The authors conclude that the left radial and right femoral arteries can be used routinely for diagnostic coronary angiography with small catheters (4 French). The left radial approach allows immediate mobilisation of the patient but the duration of the procedure and the exposure to irradiation are longer.

[Hospital results of salvage angioplasty with coronary stenting after failure of thrombolysis in the acute phase of myocardial infarction]. / Résultats hospitaliers de l'angioplastie de sauvetage avec implantation d'endoprothèses coronaires après échec de thrombolyse à la phase aiguë de l'infarctus du myocarde.

Between December 1991 and February 19999, 25 patients (56 +/- 10 years) underwent salvage angioplasty with coronary stenting after failure of thrombolysis (TIMI 2), rtPA (N = 18), n-PA (N = 4), K2-tu-PA (N = 2) and streptokinase (N = 1). All were treated by aspirin and 96% were given ticlopidine for one month. The culprit artery was the left anterior descending (48%), the left circumflex (8%) or the right coronary (44%). The average ejection fraction was 41%; 4 patients (16%) had cardiogenic shock. The stents were implanted for occlusive coronary dissection (36%), threatening dissection (40%), partial result of angioplasty (20%) or of first intention (4%). In all, 31 stents were implanted (1.2 +/- 0.57 stent/target lesion ratio with an average length of 20.9 +/- 10.2 mm). The stents were tabular in 51% of cases. The angiographic success rate (TIMI 3 and residual stenosis < 50%) was 96% with maximum inflation pressures of 13.7 +/- 2.5 atm and balloons with an average diameter of 3.3 +/- 0.5 mm. Intra-aortic balloon pumping was required in 7 patients (28%). The 30 day results included a mortality rate of 16% (4 patients), a recurrence of infarction in 4%; there were no repeat angioplasties, coronary bypass surgery or blood transfusions. The predictive factors of recurrent coronary events were: age over 60 (p = 0.04), multivessel coronary disease (p = 0.007), cardiogenic shock (p = 0.004) and left ventricular dysfunction (p = 0.015). The authors conclude that cases of failure of thrombolysis are at high risk and that salvage angioplasty with coronary stenting is associated with excellent angiographic results. Patients with cardiogenic shock, however, have a high mortality, irrespective of coronary patency and the use of intra-aortic balloon pumping.

[Balloon angioplasty]. / Angioplastie au ballonnet.

Balloon angioplasty of the coronary arteries is about 20 years old and has become the main technique of myocardial revascularisation. It is performed under local anaesthetic by arterial puncture and some centres are already performing the procedures on an ambulatory basis. Optimally, the procedure should be performed in a well-equipped catheter laboratory with trained operators and experienced personnel. The most impressive results are obtained in single vessel disease. However, double and triple vessel disease may also be treated, especially in elderly, frail patients, in cases of high surgical risk or with a previous history of coronary bypass surgery. Balloon angioplasty has an important role in the treatment of acute myocardial infarction, either as an alternative or as a complement to thrombolytic therapy. The major limitations of this technique, in the absence of stenting, are the failure to pass chronic lesions, the occurrence of major complications in about 1% of cases, of acute occlusion in about 5% of cases, and, finally, of restenosis estimated between 30 and 50%, depending on the publication. In the general population, the success rate is over 95% with an immediate return to normal life and the possibility of repeating an angioplasty in cases of restenosis. Coronary stents are a major technical adjuvant to balloon angioplasty and the indications of their implantation have exceeded 50% of procedures in recent years.

[Pre-capillary pulmonary hypertension complicating CREST syndrome. Apropos of a case]. / Hypertension artérielle pulmonaire précapillaire compliquant un syndrome CREST. A propos d'un cas.

Pre-capillary pulmonary hypertension was the presenting sign of a CREST syndrome in a 65 year old woman. The diagnosis of this form of scleroderma is based on the association of a number of features (calcinosis, Raynaud's phenomenon, oesophageal dyskinesia, sclerodactylia and telangectasia). Scleroderma is the systemic disease which is usually complicated by pre-capillary pulmonary hypertension. This complication is observed in about 13% of CREST syndromes, but very rarely as severe pre-capillary pulmonary hypertension. The diagnosis of pre-capillary pulmonary hypertension carries a poor prognosis with a 2 year survival rate of about 40%. Treatment is usually with calcium inhibitors but with no effect on prognosis. The use of prostacycline and its analogue, iloprost, is an interesting therapeutic strategy, currently under evaluation. Cardiopulmonary transplantation is the only treatment of very severe forms, despite the progressive character of the condition. All cases of pre-capillary pulmonary hypertension require complete aetiological investigation to exclude a systemic disease, especially a scleroderma and, above all, a CREST syndrome.

Primary coronary angioplasty in acute myocardial infarction excluded from thrombolysis: in-hospital and mid-term results.

The clinical, in-hospital and mid-term (14 +/- 12 months), results of primary percutaneous coronary angioplasty (PTCA) were investigated in 74 consecutive patients (pts) with acute myocardial infarction excluded from thrombolysis, of whom 9 pts with cardiogenic shock. In pts without cardiogenic shock at admission, the success rate of primary PTCA was high (92.3%) and the in-hospital mortality was low (3%). There were 89.2% asymptomatic pts during the in-hospital period. During the mid-term follow-up, pts without cardiogenic shock at admission had a mortality of only 4%, 66% of them remained asymptomatic, 24% developed angina pectoris and 6% had a new myocardial infarction. In pts with cardiogenic shock at admission to the hospital, the success rate of primary PTCA was of only 55.5% and the in-hospital mortality was high, 77.7%. In conclusion, primary PTCA in acute myocardial infarction excluded from thrombolysis is particularly useful in patients without cardiogenic shock.

[Implantation of coronary stent during the acute phase of myocardial infarction for treatment of dissection or partial result after angioplasty. Immediate results and angiographic follow-up]. / Implantation d'une endoprothèse coronaire en phase aiguë d'infarctus du myocarde pour traitement d'une dissection ou d'un résultat incomplet après angioplastie. Résultats immédiats et suivi angiographique.

Between December 1991 and November 1994, a Palmaz-Schatz stent was implanted in 9 patients aged 57 +/- 14 years during the acute phase of myocardial infarction after primary angioplasty in 7 cases and salvage angioplasty in 2 cases after an interval of 175 mm +/- 62 mn from the onset of infarction, because of threatening dissection (N = 8) or a partial result (N = 1). The success rate of implantation was 100% with residual stenosis (DCI Philips system) measured at 16 +/- 8% (5 to 28%). Anticoagulant treatment comprised heparin, coumadin and aspirin in two cases, and, in the following 7 cases, low molecular weight heparin, ticlopidine and aspirin. There was one death due to cardiogenic shock on the third day despite intraaortic balloon pumping. One patient was operated for a femoral aneurysm. A prophylactic bypass procedure was performed as a semi-emergency in a stable patient. At systematic angiographic control, the residual stenosis was measured at 19 +/- 14% (10 to 43%) without reocclusion. There was no recurrence of ischaemia. The authors conclude that the encouraging results of this short series suggest that despite the highly thrombogenic situation of acute myocardial infarction and despite the context of emergency implantation of a stent. Palmaz-Schatz stent implantation gives good immediate and long-term results with respect to reocclusion and stenosis.

Effect of the direct nitric oxide donors linsidomine and molsidomine on angiographic restenosis after coronary balloon angioplasty. The ACCORD Study. Angioplastic Coronaire Corvasal Diltiazem.

BACKGROUND: Nitric oxide (NO) donors, in addition to their vasodilator effect, decrease platelet aggregation and inhibit vascular smooth muscle cell proliferation. These actions could have beneficial effects on restenosis after coronary balloon angioplasty. METHODS AND RESULTS: In a prospective multicenter, randomized trial, 700 stable coronary patients scheduled for angioplasty received direct NO donors (infusion of linsidomine followed by oral molsidomine) or oral diltiazem. Treatment was started before angioplasty and continued until 12 to 24 hours before follow-up angiography at 6 months. The primary study end point was minimal lumen diameter, assessed by quantitative coronary angiography, 6 months after balloon angioplasty. Clinical variables were well matched in both groups. However, despite intracoronary administration of isosorbide dinitrate, the reference diameter in the NO donor group was significantly greater than in the diltiazem group on the preangioplasty, postangioplasty, and follow-up angiograms. Pretreatment with an NO donor was associated with a modest improvement in the immediate angiographic result compared with pretreatment with diltiazem (minimum luminal diameter, 1.94 versus 1.81 mm; P = .001); this improvement was maintained at the 6-month angiographic follow-up (minimal lumen diameter, 1.54 versus 1.38 mm; P = .007). The extent of late luminal narrowing did not differ significantly between groups (loss index in the NO donor and diltiazam groups, 0.35 +/- 0.78 and 0.46 +/- 0.74, respectively; P = .103). Restenosis, defined as a binary variable (> or = 50% stenosis), occurred less often in the NO donor group (38.0% versus 46.5%; P = .026). Combined major clinical events (death, nonfatal myocardial infarction, and coronary revascularization) were similar in the two groups (32.2% versus 32.4%). CONCLUSIONS: Treatment with linsidomine and molsidomine was associated with a modest improvement in the long-term angiographic result after angioplasty but had no effect on clinical outcome. The improved angiographic result related predominantly to a better immediate procedural result, because late luminal loss did not differ significantly between groups.

[Rheumatoid aortic insufficiency. Apropos of a case treated by mechanical valve replacement. Review of the literature]. / Insuffisance aortique rhumatoïde. A propos d'un cas traité par remplacement valvulaire mécanique. Revue de la littérature.

Rheumatoid valve lesions have been described for a long time in the literature. The authors report a case of rheumatoid aortic incompetence presenting with complete heat failure and treated semi-urgently by mechanical valve replacement. The pathological lesions observed on the aortic valves were pathognomonic of rheumatoid arthritis. Transthoracic echocardiography should be systematically proposed in the context of severe rheumatoid arthritis looking for valvular heart disease.

[Coronary embolism disclosing thrombosis on a Medtronic-Hall aortic valve prosthesis in aortic position]. / Embolie coronaire révélant une thrombose d'une prothèse valvulaire mécanique de Medtronic-Hall en position aortique.

A 32 year-old-man admitted to hospital on the third day of myocardial infarction, three months after aortic valve replacement with a mechanical Medtronic-Hall prosthesis. The embolic character of the disease was evident on coronary angiography which showed a large thrombus in the left main coronary artery. The thrombosis of the valve prosthesis was not detected by non-invasive investigations but at aortography, confirmed at surgery. Thrombolysis with rt-PA did not dissolve the clot and reoperation was necessary (valve replacement with aorto-coronary bypass grafting).

[A rare cause of pure isolated chronic aortic insufficiency: congenital quadricuspid aortic valve. Apropos of 2 cases]. / Une cause rare d'insuffisance aortique pure, isolée et chronique: la quadricuspidie aortique congénitale. A propos de deux cas.

The authors report two new cases of congenital quadricuspid aortic valve complicated by pure, severe, chronic, aortic regurgitation. This abnormality was diagnosed fortuitously at transoesophageal echocardiography in one case and at aortography in the other, and confirmed at surgery. This congenital abnormality was associated with superior displacement of the left coronary ostium.

[Value of early stress test during treatment after myocardial infarction with Q wave in patients under 55 years of age]. / Valeur de l'épreuve d'effort précoce et sous traitement après un infarctus du myocarde avec onde Q chez les patients âgés de moins de 55 ans.

We studied one hundred consecutive patients, under the age of 55 years (mean age: 45.6 years), with myocardial infarction and a Q wave, in order to assess the prognostic value of an early stress test. Thirty five patients were excluded: 2 deaths, 21 revascularizations during the acute phase, 4 tests were performed without treatment, 6 tests were unable to be performed and 2 patients left hospital against medical advice. Sixty five patients [males, n = 60 (92.2%), anterior infarction, n = 25 (38.5%), thrombolysed n = 35 (53.8%), intact left ventricular ejection fraction (mean: 54.7%)] systematically underwent a stress test limited by symptoms, in hospital, on the tenth day of infarction, using an ergometric bicycle and under medical treatment (including beta blockers n = 47 (72.2%)] and cardiac catheterization. The test was considered positive when it was accompanied by angina and/or ST depression (n = 19), negative in the absence of these criteria for a level of 120 watts (n = 23), inadequate when the duration was less than 9 minutes and when the heart rate was less than or equal to 70% of the theoretical maximal heart rate (n = 11), doubtful when there was accentuation of ST elevation in the infarcted territory with mirror ST depression (n = 12). Only 30.7% of patients had multi-vessel coronary lesions (two- and three-vessel disease). The mortality was 4.6% with a mean follow-up of 27.4 months (range: 3-38). The sensitivity of the test for detection of multi-vessel disease was 62.5%, the specificity was 65.3%, the positive predictive value was 52.6%, and the negative predictive value was 73.9%. The sensitivity of this test, with beta-blocker treatment, to predict coronary lesions or cardiac events, fell to 33.3% and 37.5%, respectively. The stress test during the post-infarction period, with beta-blocker treatment, appears to be less sensitive for the identification of multivessel disease and cardiac events: this treatment should therefore be suspended before performing this test when allowed by the patient's clinical state.

[Infarction in young women caused by intracoronary thrombosis on angiographically normal arteries: apropos of a case]. / Infarctus de la femme jeune par thrombose intracoronaire sur artère angiographiquement normale; à propos d'un cas.

Myocardial infarction is a rare clinical event in young women. The usual presentation is similar to that of older adults. The authors report a case of anteroseptal infarction in a 24 year old woman presenting with paroxysmal epigastric pain without irradiation with fever, during menstruation. The electrocardiogram was compatible with acute pericarditis. The diagnosis was rectified by echocardiography which showed anteroseptal akinesia. Coronary angiography performed as an emergency showed a radiolucent mobile image in the mid segment of the left anterior descending artery with appearances of a distal embolism which were attributed to thrombosis. Intracoronary thrombolysis was associated with a good outcome.

[Anterior mediastinal cyst disclosed by protracted thoracic pain]. / A propos d'un kyste du médiastin antérieur révélé par une douleur thoracique prolongée.

The authors report a case of anterior mediastinal cyst discovered incidentally in a 71-year-old man presenting with prolonged chest pain and a history of chronic renal failure secondary to polycystic kidney disease. The diagnosis of these cysts, which are benign congenital tumours usually asymptomatic and with a favourable course, was established by thoracic CT. In difficult cases, magnetic resonance imaging allows precise analysis of pericardial masses. Clinicians should think of this possibility in the presence of an opacity of the cardiophrenic angle associated with chest pain.

[Angioplasty after failure of thrombolysis in myocardial infarction. Hospital results apropos of 40 consecutive patients]. / Angioplastie après échec de thrombolyse dans l'infarctus du myocarde. Résultats hospitaliers à propos de 40 patients consécutifs.

Intravenous thrombolysis during the acute phase of myocardial infarction is successful in restoring perfusion in 60 to 80% of cases. When it is unsuccessful, there is disagreement about the best approach to adopt. The article reports the results obtained in 40 consecutive patients treated by angioplasty after thrombolysis had been unsuccessful. Reperfusion was achieved in 92.5% of cases, with a hospital mortality rate of 7.5% (2.5% if patients admitted in a stage of cardiogenic shock are excluded). There was no mortality related to the procedure itself and an emergency aorto-coronary by-pass was not required in any case. Since it is accepted that the subsequent prognosis depends on coronary patency, coronary artery assessment after thrombolysis, followed by angioplasty if the occlusion persists seems to be a logical strategy if the myocardial territory is compromised.

[Partial abnormal pulmonary venous return. An underestimated and unknown association in Turner-Ullrich syndrome. Presentation of an original case]. / Retour veineux pulmonaire anormal partiel. Une association sous-estimée et mal connue dans le syndrome de Turner-Ullrich. Présentation d'une observation originale.

The authors report the case of a 59-year-old woman with a complex cardiac lesion consisting of degenerative major mitral insufficiency masking partial abnormal pulmonary venous return. These cardiac abnormalities fell within a context of genetic disease since the patient had Turner's syndrome, confirmed at the age of 58 by a 45 x 0 karyotype. They detail the originality of the clinical manifestations of partial abnormal pulmonary venous return and review the literature concerning cardiac malformations in Turner's syndrome.