[Influence of percutaneous coronary intervention in non ST-elevation acute coronary syndromes on prescription of secondary prevention medications. Data from the S-Témoin Registry]. / Prevention secondaire après syndrome coronaire aigu sans sus-décalage de ST en fonction de l'utilisation de l'angioplastie coronaire: l'étude S-Témoin.

BACKGROUND: The interaction between the use of percutaneous coronary intervention (PCI) for non-ST-elevation acute coronary syndromes and the use of secondary prevention medications was analysed in the French S-Témoin Registry. METHODS: The population consisted of 2433 patients seen by their cardiologists at an outpatient clinic 2-12 months after non ST-elevation ACS; the survey was carried out from September 2004 to April 2005. RESULTS: Overall, patients undergoing PCI (75% of the population) had higher levels of prescription of recommended secondary prevention medications. Multivariate logistic regression analysis showed that the use and type of coronary intervention (drug eluting versus bare metal stents) was an independent correlate of the use of dual antiplatelet therapy. In addition, time from the acute episode was also a strong correlate of dual antiplatelet therapy. Statins were also more often used in patients with PCI. CONCLUSION: Patients not treated with PCI are less likely to receive appropriate secondary prevention medications after non ST-elevation acute coronary syndromes. Specific efforts should be directed towards these patients, in particular as regards the prescription of dual antiplatelet therapy.

[Management of the cardiology patient with polyvascular disease: PRISMA study]. / Prise en charge du patient polyvasculaire en cardiologie de ville. Résultats de l'étude PRISMA.

INTRODUCTION: Myocardial infarction (MI), peripheral vascular disease and ischaemic cerebral vascular accident (CVA) are three manifestations of the same disease, atherothrombosis, and they share the same pathophysiology and prognosis. OBJECTIVE: The aim of this work was to describe the clinical characteristics and the medical management of polyvascular patients in cardiology. METHOD: Cardiologists from all over the country participated in a consultation register for 3 weeks. The clinical characteristics and medical management for the first 3 patients on the register for each cardiologist were studied in a national multicentre study and then compared according to whether the atherothrombotic disease was isolated or polyvascular. RESULTS: In total, 100,429 patients were examined during the period of the register and 2,780 were included in the study. Polyvascular patients represented 7% of the register and 22% of the vascular patients. These patients with multiple manifestations were frequently diabetics. A lipid profile was available less often in the cardiac patients when they had another disorder (72.4%) than in the case of an isolated disorder (78.9%). Whatever the initial disorder, dyslipidaemia was less often controlled in the case of polyvascular disease (63% of LDL-C > or = 1.3g/l in polyvascular cardiac patients vs 52% in cardiac patients with isolated disease). In cardiac patients, the presence of peripheral vascular disease was associated with less prescription of beta blockers (OR=0.4 [0.3-0.6]), the presence of CVA was associated with less prescription of statins (OR=0.7 [0.5-0.9]). Eight out of 10 polyvascular patients received anti-platelet aggregation treatment. The presence of multiple atherothrombotic manifestations was associated with greater prescription of ACEI, except in cardiac patients. CONCLUSION: These results improve our understanding of the specific management of polyvascular patients, for whom secondary prevention is paramount due to the higher risk of recurrence. They should prompt the reinforcement of measures which have been shown to be effective, such as managing major risk factors, and in particular the dislipidaemias.

[Trends in discharge prescriptions for patients hospitalized for acute coronary syndromes in France from 1995 to 2000. Data from the Usik 1995, Prevenir 1, Prevenir 2 and Usic 2000 surveys]. / Evolution du traitement de sortie après hospitalisation pour syndrome coronaire aigu en France entre 1995 et 2000: données des études Usik 1995, Prévenir 1 et 2 et Usic 2000.

The use of cardiovascular secondary prevention medications in patients with acute coronary syndromes was compared in 4 sequential observational surveys carried out in France from 1995 to 2000. The Usik 1995 and Usic 2000 surveys included patients admitted for acute myocardial infarction, while the 2 Prevenir surveys (1998 and 1999) assessed the medications prescribed in patients with acute coronary syndromes. Antiplatelet agents were prescribed in 91% of the patients in 1995, 93% in 1998 and 1999 and 96% in 2000; for beta-blockers, the respective figures were: 64%, 68%, 75% and 76%. For ACE-Inhibitors, the figures were: 46%, 41%, 41% and 50%. For statins, the prescription increased from 10% to 36%, 59% and 64%. In 1995, 8% of the patients received both antiplatelet agents, beta-blockers and statins (4% of them also had an ACE-Inhibitor); in 2000, the respective figures were 53% and 27%. The results of the recent trials of secondary prevention medications have had a considerable impact on real-life practice in France during the late 1990s.

[Factors influencing secondary prevention of atherothrombotic disease in the private outpatient cardiology setting: results of the Prisma survey]. / Etude sur les facteurs influençant les prescriptions en prévention secondaire de la maladie athérothrombotique en pratique de ville: résultats de l'étude Prisma.

From March to July 1999, 940 private cardiologists in France recruited 100,429 patients of whom 30,430 (30%) had a previous history of atherothrombotic disease. The prevalence of patients with a previous history of Myocardial Infarction (MI), Ischemic Stroke (IS) or Peripheral Arterial Disease (PAD) was 19.7%, 7.2% and 10.7% respectively. Among patients with a history of atherothrombotic disease, myocardial infarction was the most frequent diagnosis responsible for 65% of all consultations. Each cardiologist described the secondary prevention treatment for 3 consecutive patients among whom 1 corresponded to each of the 3 atherothrombotic territories. The most frequent cardiovascular risk factors were hypercholesterolemia for myocardial infarction (77.9%), smoking for PAD (32.5%) and hypertension for IS (73.2%). Diabetes mellitus (1/4 patients), obesity (1/3) and sedentary way of life (1/3) were equally prevalent for each of the atherothrombotic territories. More than 90% of the patients received an antithrombotic drug. Antiplatelet agents were largely prescribed, anticoagulants being more frequently used for patients with atrial fibrillation, symptomatic cardiac heart failure or stroke of embolic origin. Thienopyridines represent 17.9% of the prescriptions. The prescription rate of statins after MI (58.9%) is lower than in published studies in secondary prevention. The lack of lipid measurement and the delay since last measurement are non-prescription factors. The rates of prescription are even lower in case of PAD (44.6%) or IS history (33.3%). More than half of the patients (56.6%) are treated with beta-blockers and 40.1% with ACE inhibitors. These rates are similar to what has been published. Atherothrombotic disease represents a large part of the daily activity of private cardiologists and is not limited to coronary heart disease. Despite their proven efficacy, drugs for secondary prevention for MI, except antithrombotic drugs, are insufficiently prescribed. This under-prescription is even higher in patients with PAD or IS history and may be related to the lack of clinical trials in these specific territories.

[Baseline characteristics and management of patients less than 45 years of age hospitalized for acute coronary syndromes: results from the nationwide French PREVENIR 1 and PREVENIR 2 studies]. / Caractéristiques initiales et prise en charge thérapeutique des sujets jeunes (âge inférieur à 45 ans) hospitalisés pour syndrome coronaire aigu: résultats des études françaises PREVENIR 1 et PREVENIR 2.

Of 2,626 patients admitted for acute coronary syndromes and participating in the PREVENIR 1 and 2 registries, 202 (8%) were aged less than 45 years. Younger patients were more often smokers (79% versus 37%), but systemic hypertension and diabetes were less frequent. Reperfusion therapy was more frequently used in the younger patients (63% versus 46%). At hospital discharge, aspirin and angiotensin converting enzyme inhibitors were prescribed as often in younger and older patients. In contrast, beta-blocking agents and statins were used more often in the younger patients. More younger patients participated in a cardiac rehabilitation programme. Left ventricular ejection fraction was less altered in the younger age group and none of the younger patients died between hospital discharge and six months follow-up.

Hypertension control at hospital discharge after acute coronary event: influence on cardiovascular prognosis--the PREVENIR study.

OBJECTIVE: To assess hypertension control in patients admitted to hospital for an acute coronary event and to investigate the influence on prognosis of controlling hypertension before hospital discharge. DESIGN: Multicentre retrospective cohort study. METHODS: The medical records were examined of all patients admitted in 77 cardiological centres on January 1998 for myocardial infarction or unstable angina and who survived. Clinical characteristics, blood pressure at hospital discharge, and cardiovascular events during a six month follow up were recorded. MAIN OUTCOME MEASURES: Cardiovascular deaths and non-fatal myocardial infarction. RESULTS: Data were available in 1247 patients. At discharge, 411 (32.9%) had uncontrolled hypertension; among these, 276 (22.1%) were uncontrolled on the basis of systolic blood pressure alone. Forty three cardiovascular deaths and 20 non-fatal myocardial infarcts occurred during follow up. In a multivariate analysis, age, left ventricular ejection fraction, previous history of cardiovascular disease, and isolated systolic hypertension (odds ratio 1.9, 95% confidence interval 1.07 to 3.37) were associated with the outcome. CONCLUSIONS: 22.1% of patients admitted to hospital for an acute coronary syndrome have uncontrolled isolated systolic hypertension on discharge. This appears to be an independent predictor of cardiovascular outcome.

Use of secondary preventive drugs in patients with acute coronary syndromes treated medically or with coronary angioplasty: results from the nationwide French PREVENIR survey.

BACKGROUND: There is evidence that several classes of drugs are beneficial for secondary prevention in patients with coronary artery disease. OBJECTIVE: To compare the use of secondary preventive drugs in patients with acute coronary syndromes given conservative treatment or percutaneous coronary interventions. DESIGN: The PREVENIR survey was designed to assess the management of patients with acute coronary syndromes admitted to hospital in France in January 1998. Drugs prescribed at hospital discharge were recorded retrospectively from the hospital records, and treatment at six months was assessed prospectively. SETTING: University hospitals, general hospitals, and private clinics throughout the country. RESULTS: Of 1394 patients participating in the survey, 668 underwent coronary angioplasty during the initial hospital stay and 706 had medical treatment only. At hospital discharge, aspirin, beta blockers, and statins were prescribed significantly more often in patients undergoing angioplasty. Using multivariate logistic regression, coronary angioplasty was an independent predictor of treatment with aspirin (odds ratio 3.55), statins (1.92), and beta blockers (1.41). Compared with treatment at discharge, only statin use differed at six months, with a significant increase both in patients treated medically and in those who had undergone angioplasty. Increased use of statins, aspirin, and beta blockers was significantly correlated with coronary angioplasty during the initial hospital stay. CONCLUSIONS: In this national French survey, patients treated with percutaneous coronary interventions were more likely to receive secondary preventive drugs than patients receiving medical treatment alone.

[Blood pressure control after acute coronary events. Results of the PREVENIR study]. / Contrôle tensionnel après un événement coronaire aigu. Résultats de l'étude PREVENIR.

OBJECTIVE: The difficulty in controlling hypertension in coronary patients has been underlined. The aim of the study was to assess blood pressure profile (BP) at hospital discharge in a large population of survivors of an acute coronary syndrome. DESIGN AND METHODS: An observational study was conducted in France in 77 cardiological centers. The medical records of all patients admitted in these hospitals on January 1998 for a myocardial infarction or unstable angina and who survived were studied. Clinical characteristics and BP at hospital discharge were recorded. Patients with blood pressure > or = 140/90 mmHg were considered as uncontrolled hypertensives (HT). RESULTS: Data were available in 1327 of the 1394 patients recruited: at hospital discharge, 344 patients (25.9%) were controlled and 431 (32.4%) were uncontrolled hypertensives. Among these patients, 406 (94.1%) had systolic blood pressure > or = 140 mmHg, 139 (32.2%) had diastolic blood pressure > or = 90 mmHg and 292 patients (67.7%) had systolic blood pressure > or = 140 mmHg and diastolic blood pressure < 90 mmHg. Pulse pressure in controlled hypertensives (51.02 +/- 10.93 mmHg) was quite similar to that in normotensives (47.81 +/- 9.84 mmHg) whereas pulse pressure was significantly higher in uncontrolled hypertensives (65.86 +/- 13.29 mmHg). CONCLUSION: At hospital discharge after a coronary event, arterial hypertension is uncontrolled in 32.4% of patients mainly because of poor systolic blood pressure control. Achieving normal blood pressure throughout the hospitalisation should improve long term blood pressure control, reduce pulse pressure and improve the prognosis in this high risk population.

[Distribution and treatment of cardiovascular risk factors in coronary patients: the Prevenir Study]. / Distribution et prise en charge des facteurs de risque cardiovasculaires chez des patients coronariens: étude Prévenir.

The aim of this study was to evaluate the distribution and hospital treatment of cardiovascular risk factors in coronary patients. A transverse observational study was carried out in 77 cardiological centres throughout France. All patients with a history of myocardial infarction or of unstable angina during the month of January 1998 were enrolled. The clinical features of 1334 patients (71.4% men, 746 myocardial infarction, 588 unstable angina) on hospital admission were analysed. The prevalence of smoking, dyslipidaemia, hypertension and obesity was 49, 45, 42, 19 and 11% respectively in the men and 17, 46, 63, 23 and 10% respectively in the women. The number of treatable risk factors slightly decreased in the oldest age group. The prevalence of hypertension increased with age whereas smoking and dyslipidaemia decreased in both men and women. Obese and diabetic patients had more risk factors than the others. A little less than half of patients with dyslipidaemia were under no preventive measures (diet and/or lipid-lowering drugs) and 40% of men with a previous history of coronary artery disease continued to smoke. The authors conclude that men over 85 and women over 75 years of age have fewer risk factors than other age groups and the type of risk factor varies with age. The treatment of dyslipidaeamia and smoking is still inadequate and should be improved.

Captopril does not acutely modulate plasma endothelin-1 concentration in human congestive heart failure.

Congestive heart failure (CHF) is a syndrome characterized by increased levels of angiotensin II (Ang II) and endothelin-1 (ET-1). In vitro, Ang II stimulates ET-1 release. The purpose of the study was to assess the effect of a single dose of an angiotensin-converting enzyme inhibitor (ACEI) captopril versus placebo on plasma endothelin concentration in human congestive heart failure. Captopril (25 mg, given orally) was compared with placebo in a group of 20 patients with systolic dysfunction in a double-blind randomized study. Plasma irET concentration was significantly increased in CHF patients compared with normal subjects (5.59 pg/ml +/- 0.35 vs. 3.58 pg/ml +/- 0.99, p < 0.0002). Despite the decrease in systolic blood pressure and the increase in plasma renin activity, suggesting a significant blockade of the renin-angiotensin system, no difference in plasma irET-1 was observed between captopril and placebo. Our results suggest that captopril does not acutely influence irET-1 plasma concentration in human CHF. These data do not support the hypothesis that the acute vasodilator effect of a single dose of 25 mg of captopril given daily orally involves modulation of the increased plasma concentration of endothelin observed in CHF.

[Ambulatory treatment of chronic cardiac insufficiency]. / Le traitement ambulatoire de l'insuffisance cardiaque chronique.

Considerable progress has been made in the medical treatment of chronic heart failure. A large number of patients with NYHA class II and III heart disease can be improved to class I and II. Treatment is maintained on an outpatient basis in order to prevent episodes of acute failure, while avoiding the adverse effects of drugs at high doses or in combination. Diuretics are still the drug class most frequently prescribed, especially loop diuretics (furosemide) which have the advantage of being able to be used in patients with renal failure. Aldosterone antagonists have the pathophysiological value of reducing the development of myocardial fibrosis. Digitalis alkaloids have a positive inotropic effect, which is even observed in the presence of sinus rhythm and which is associated with slowing of the heart rate in tachyarrhythmias. Angiotensin converting enzyme inhibitors are among the most recently used drugs. They decrease the left ventricular post-load and prevent activation of the renin-angiotensin-aldosterone system. Phosphodiesterase inhibitors cannot be administered orally in the long-term and are therefore not suitable for outpatient treatment. However, they are very effective by intravenous injection during the acute phase of heart failure and cardiogenic shock in hospital.

Toxoplasma pericarditis in acquired immunodeficiency syndrome.

Large pericardial effusions are now a well-known complication of the acquired immunodeficiency syndrome, mainly caused by mycobacterial disease. However, other etiologies can be found. We report a case of toxoplasma pericarditis without other parasitic localizations. Pericarditis is a very uncommon clinical feature during toxoplasmosis. Its diagnosis is often difficult to establish, particularly in immunocompromised patients. Nevertheless, its possible evolution to constriction or tamponade requires its consideration. New methods of rapid tissue cultures may be helpful and allow early specific treatment.

[How to evaluate a patient with heart failure? Round table]. / Comment évaluer un malade atteint d'insuffisance cardiaque? Table ronde.

Evaluation of heart failure is the first step prior to introduction of an adapted therapeutic strategy. Three principal objectives must be defined: 1) identify the cause of heart failure, which may directly guide subsequent treatment (valvular heart disease, coronary artery disease, etc.); 2) evaluate the repercussions of heart failure on everyday life: evaluation of quality of life, severity of functional disorders and reduction of the everyday capacity. This evaluation is the most delicate as it is based on clinical interview: evaluation of the various NYHA stages lacks precision and reproducibility. The stress test with measurement of oxygen consumption appears to constitute an acceptable evaluation technique; 3) evaluation of the prognosis. Many studies have demonstrated precise relationships between life expectancy and a number of criteria, alteration of myocardial function, echocardiographic findings, ejection fraction, cardiac output and even an AP chest x-ray. Although statistically valid, these criteria have a limited application in individual patients. Evaluation of all these parameters is the most accurate way to predict the subsequent course of the disease which therefore allows a more accurate choice of treatment and subsequent evaluation of their efficacy.

Plasma calcitonin gene-related peptide decreases in chronic congestive heart failure.

To investigate the role of calcitonin gene-related peptide (CGRP) in cardiac failure, a sensitive and specific radioimmunoassay was developed to study plasma levels of CGRP in 37 normal subjects and 41 patients with heart failure (HF). The mean plasma levels of CGRP were 294.3 pg.ml-1 (SEM: 41.4) in normal subjects and 121.2 pg.ml-1 (SEM: 21.2) in HF patients. The significant decrease observed in HF patients suggests that CGRP is involved in the pathogenesis of heart failure via a direct effect or via modulation of sympathetic nervous activity.