Predictors of angiographically visible distal embolization in STEMI.

BACKGROUND: Distal embolization during primary percutaneous coronary intervention (p-PCI) in the treatment of ST-segment elevation myocardial infarction (STEMI) is associated with a poor prognosis. In this situation, thrombectomy is performed to prevent distal embolization and to restore myocardial reperfusion. The aim of our study was to determine angiographic predictors of angiographically visible distal embolization (AVDE) in patients with STEMI treated by p­PCI with thrombectomy. PATIENTS AND METHODS: This prospective study included all consecutive patients who underwent p­PCI with thrombectomy for STEMI at our institution between October 2011 and December 2014 AVDE was defined as a distal filling defect with an abrupt cut-off in one of the peripheral coronary branches of the infarct-related artery, distal to the angioplasty site. Thrombectomy was considered positive when it removed thrombi, and successful when it improved coronary flow. RESULTS: Among the 346 patients included, 59 (17%) developed AVDE during p­PCI. In multivariate analysis, the infarct-related right coronary artery (OR: 2.48, 95% CI: 1.36-4.52; p = 0.003) and a culprit lesion diameter of >3 mm (OR : 1.90, 95% CI: 1.01-3.56; p = 0.048) were identified as independent factors associated with AVDE during p­PCI with thrombectomy for STEMI. The success of thrombectomy and the Syntax score were not associated with AVDE. CONCLUSION: AVDE complicating p­PCI with thrombectomy in STEMI is frequent (17%) and a successful thrombectomy does not rule out AVDE.

Impact of the dynamic and static component of the sport practised for electrocardiogram analysis in screening athletes.

To interpret the electrocardiogram (ECG) of athletes, the recommendations of the ESC and the Seattle criteria define type 1 peculiarities, those induced by training, and type 2, those not induced by training, to rule out cardiomyopathy. The specificity of the screening was improved by Sheikh who defined "Refined Criteria," which includes a group of intermediate peculiarities. The aim of our study was to investigate the influence of static and dynamic components on the prevalence of different types of abnormalities. The ECGs of 1030 athletes performed during preparticipation screening were interpreted using these three classifications. Our work revealed 62/16%, 69/13%, and 71/7% of type 1 peculiarities and type 2 abnormalities for the ESC, Seattle, and Refined Criteria algorithms, respectively(P<.001). For type 2 abnormalities, three independent factors were found for the ESC and Seattle criteria: age, Afro-Caribbean origin, and the dynamic component with, for the latter, an OR[95% CI] of 2.35[1.28-4.33] (P=.006) and 1.90[1.03-3.51] (P=.041), respectively. In contrast, only the Afro-Caribbean origin was associated with type 2 abnormalities using the Refined Criteria: OR[95% CI] 2.67[1.60-4.46] (P<.0001). The Refined Criteria classified more athletes in the type 1 category and fewer in the type 2 category compared with the ESC and Seattle algorithms. Contrary to previous studies, a high dynamic component was not associated with type 2 abnormalities when the Refined Criteria were used; only the Afro-Caribbean origin remained associated. Further research is necessary to better understand adaptations with regard to duration and thus improve the modern criteria for ECG screening in athletes.

Severe cardiomyopathy revealing antineutrophil cytoplasmic antibodies-negative eosinophilic granulomatosis with polyangiitis.

Eosinophilic granulomatosis with polyangiitis (EGPA) is a rare form of systemic vasculitis in which cardiac involvement is frequent and severe, and accounts for half of EGPA-related deaths. ANCA-positive EGPA differs from ANCA-negative EGPA in that the former is significantly associated with renal involvement, peripheral neuropathy and biopsy proven vasculitis, whereas the latter is associated with cardiac involvement. Herein, we report a case of EGPA with myocarditis in a woman, who was successfully treated with steroids and cyclophosphamide. This report highlights the importance of diagnosing cardiac involvement in EGPA early, especially in ANCA-negative patients.

[Retinal vascular network: Changes with aging and systemic vascular disease (cardiac and cerebral)]. / Caractéristiques vasculaires rétiniennes : modifications lors du vieillissement et en pathologie vasculaire systémique (cardiaque et cérébrale).

For over 10 years, the description of the retinal microvascular network has benefited from the development of new imaging techniques. Automated retinal image analysis software, as well as OCT angiography (OCT-A), are able to highlight subtle, early changes in the retinal vascular network thanks to a large amount of microvascular quantitative data. The challenge of current research is to demonstrate the association between these microvascular changes, the systemic vascular aging process, and cerebrovascular and cardiovascular disease. Indeed, a pathophysiological continuum exists between retinal microvascular changes and systemic vascular diseases. In the Montrachet study, we found that a suboptimal retinal vascular network, as identified by the Singapore I Vessel Assessment (SIVA) software, was significantly associated with treated diabetes and an increased risk of cardiovascular mortality. In addition, we supplemented our research on the retinal vascular network with the use of OCT-A. In the EYE-MI study, we showed the potential role of quantitative characterization of the retinal microvascular network by OCT-A in order to assess the cardiovascular risk profile of patients with a history of myocardial infarction. A high AHA (American Heart Association) risk score was associated with low retinal vascular density independently of hemodynamic changes. Thus, a better understanding of the association between the retinal microvasculature and macrovascular disease might make its use conceivable for early identification of at-risk patients and to suggest a personalized program of preventative care. The retinal vascular network could therefore represent an indicator of systemic vascular disease as well as an interesting predictive biomarker for vascular events.

[Comparison of the prognostic value of different clinical, angiographic and scintigraphic scores in stable coronary patients after acute coronary syndrome]. / Étude et comparaison de la valeur pronostique de différents scores clinique, coronarographique et scintigraphique chez le patient coronarien stable après un syndrome coronarien aigu.

INTRODUCTION: To date, there is no consensus regarding the follow-up of asymptomatic coronary patients with an intermediate risk of events. Indeed, most of cardiovascular events (CVE) occur in asymptomatic patients, hence the clinician's interest in establishing risk stratification scores. In asymptomatic patient, the risk assessment after acute coronary syndrome (ACS) can currently be based on 3 types of score: clinical with, for example, the REACH score; angiographic with the residual SYNTAX score; imaging with different scintigraphic scores. These scores differ widely in terms of evaluation criteria and period of analysis. The aim of our study was therefore, in stable and asymptomatic coronary patients after ACS, to compare these different predictive scores; to establish that the combination of these scores makes it possible to optimize the risk assessment during the follow-up. METHODS: Our retrospective study included 236 revascularized patients after ACS. Three different risk scores were collected: 1) the residual SYNTAX score, calculated at the time of revascularization; 2) the scintigraphic risk score described by Sharir et al., performed 3 to 12 months after the event and taking into account the extent of ischemia (SDS) and the poststress left ventricular ejection fraction (LVEF). Patients with LVEF <50% and/or moderate to severe ischemic disease (SDS≥2) were considered with an intermediate or high scintigraphic risk; 3) the REACH clinical score calculated on the day of the scintigraphic examination. After the myocardial scintigraphic exam, patients had a 1-year follow-up and CVE were recorded. Continuous data were analyzed either by Student's t-test or non-parametric Mann-Whitney test. The dichotomous data were compared either by the χ2 test or by Fisher's exact test. RESULTS: Forty-eight patients (20.1%) had a CVE during the 1-year follow-up. Thirty patients (13.8%) had a high residual SYNTAX score (≥8) without any correlation observed between the residual SYNTAX score and CVE (P=0.359). 148 patients (57.7%) had a high REACH clinical score (≥11) with no significant correlation observed with CVE (P=0.079). Lastly, 34 patients (14.4%) had an intermediate or high scintigraphic score, this imaging score being strongly correlated with a greater number of CVE (P<0.001). Multivariate analysis revealed 3 independent factors associated with CVE: a scintigraphic score> 2 (OR [(95% CI): 5.530 [2.426-12.605] P<0.001); Peripheral Arterial Obstructive Disease (PAOD) (OR [95% CI]: 8.531 [2.540-28.660] P<0.001); diabetes (OR [95% CI]: 2.86 [1.262-6.517] P=0,012). CONCLUSION: The combination of the scintigraphic score with two clinical factors, such as PAOD and diabetes, provides optimal prognostic value in the evaluation of asymptomatic and stable patients after ACS. Our study therefore highlights the importance of optimizing evaluation strategies in the follow-up of these patients who remain at risk of post-revascularization CVE.

[Prognostic value of HbA1c and plasma glucose on one-year mortality in non-diabetic patients after myocardial infarction]. / Impact pronostique de l'HbA1c et de la glycémie plasmatique (Gp) à la phase aiguë d'un infarctus du myocarde sur la mortalité à un an chez des patients non diabétiques.

BACKGROUND: The usefulness of the combined assessment of HbA1c and plasma glucose (PG) in acute myocardial infarction (AMI) in non-diabetic patients remains unclear. PURPOSE: In a large observational study, we aimed to identify the prognostic values of these biomarkers regarding one-year all-cause mortality in non-diabetic patients after AMI. METHODS: From the "obseRvatoire des Infarctus de Côte d'Or" (RICO) survey database, we included all consecutive non-diabetic patients with AMI (n=6617) from May 2001 to December 2016. Exclusion criteria were: admission known or unknown diabetes, in-hospital death. The primary endpoint was all-cause one-year mortality. The secondary endpoints were: MACE, infarct size, LVEF<40% and GRACE risk score. Cut-off levels (high/low) were determined by ROC curve analysis for the prediction of one-year death (HbA1c 5.9% and PG 131mg/dL) to set up 4 groups: low HbA1c/low glucose (n=3158), low HbA1c/high glucose (n=1264), high HbA1c/low glucose (n=1378) and high HbA1c/high glucose (n=817). RESULTS: Elevation of PG was associated with elevated rate of LVEF<40%, STEMI, anterior wall location, DFG<60mL/min/m2 and higher troponin Ic pic (all P<0.001); HbA1c>5.9% was associated with elevated rate of CRP>3mg/L (P<0.001); high HbA1c and high PG together were associated with higher rate of MACE (P<0.001). By multivariate logistic regression analysis, elevated admission PG remained a strong predictor of one-year all-cause [OR (95%CI): 1.64 (1.31-2.05)] mortality and cardiovascular mortality [OR (95%CI): 1.75 (1.33-2.31)], beyond GRACE score [OR (95%CI): 1.03 (1.03-1.04)], as well as elevated HbA1c [OR (95%CI): 1.43 (1.15-1.78) and OR (95%CI): 1.83 (1.39-2.41) respectively]. CONCLUSIONS: Admission PG and HbA1c had strong independent predictive value regarding one-year all-cause mortality in our non-diabetic patients with AMI. These biomarkers could be useful to identify the most-at-risk patients after AMI in order to reduce residual risk in this target population.

Influence of cardiac hemodynamic variables on retinal vessel density measurement on optical coherence tomography angiography in patients with myocardial infarction.

INTRODUCTION: Quantitative measurements of retinal microvasculature by optical coherence tomography angiography (OCT-A) have been used to assess cardiovascular risk profile. However, to date, there are no studies focusing on OCT-A imaging in the setting of the altered hemodynamic status found in high-risk cardiovascular patients. METHODS: To determine the potential association between retinal vascular density on OCT-A and a comprehensive battery of hemodynamic variables in patients with myocardial infarction (MI) using data from the acute phase and at 3 months follow-up after cardiac rehabilitation. This prospective longitudinal study included patients who presented with MI in the cardiology intensive care unit at Dijon University Hospital. Main outcomes and measurements were retinal vessel density on OCT-A, hemodynamic status based on left ventricular ejection fraction (LVEF), and indexed cardiac output during the acute phase of myocardial infarction and at 3 months follow-up. RESULTS: Overall, 30 patients were included in this pilot study. The median (IQR) age was 64 years (55-71) with 87% men. At admission, the mean (SD) LVEF was 53% (11), and the mean indexed cardiac output was 2.70 (0.83) L/min/m2. On OCT-A, the mean inner retinal vascular density was 19.09 (2.80) mm-1. No significant association was found between retinal vascular density and hemodynamic variables. CONCLUSION: We found no significant association between retinal vascular density on OCT-A and hemodynamic variables in the acute phase of a myocardial infarction or after 3 months of cardiac rehabilitation. Therefore, OCT-A findings do not seem to be influenced by the hemodynamic changes associated with myocardial infarction.

Comparative epidemiology of stroke and acute myocardial infarction: the Dijon Vascular project (Diva).

BACKGROUND: Despite a common pathophysiological mechanism (ie, atherosclerosis) and similar vascular risk factors, few reliable studies have compared the epidemiology of stroke and acute myocardial infarction (AMI). METHODS: All first ever cases of stroke and AMI in Dijon, France (151 846 inhabitants) from 2001 to 2006 were prospectively recorded. The 30 day case fatality rates (CFRs) and vascular risk factors were assessed in both groups. RESULTS: Over the 6 years, 1660 events (1020 strokes and 640 AMI) were recorded. Crude incidence of stroke was higher than that of AMI (112 vs 70.2/100 000/year; p<0.001). With regard to sex, the relative incidence of stroke compared with AMI was 0.88 (95% CI 0.60 to 1.29; p = 0.51) in women <65 years and 2.32 (95% CI 1.95 to 2.75; p<0.001) in those >65 years whereas it was 0.60 (95% CI 0.42 to 0.86; p<0.001) in men below 55 years, 1.01 (0.81 to 1.24, p = 0.96) in those between 55 and 75 years and 2.01 (95% CI 1.48 to 2.71; p<0.001) at 75 years and older. CFRs at 30 days were similar for stroke and AMI (9.80% vs 9.84%; p = 0.5). Hyperglycaemia (>7.8 mmol/l) at onset was significantly associated with higher CFR in both stroke and AMI patients. The prevalence of male sex, hypercholesterolaemia and diabetes was higher in AMI patients whereas hypertension was more frequent in stroke patients. CONCLUSION: These findings will help health care authorities to evaluate future needs for stroke and AMI services, and to develop secondary prevention strategies.

Dijon's vanishing lead with regard to low incidence of stroke.

BACKGROUND: Towards the end of the 20th century, the city of Dijon, France, had a lower incidence of stroke than that found in other studies. It was hypothesized that genetic and environmental factors were responsible for this so-called French paradox. We aim to evaluate recent changes in stroke incidence to determine whether or not the Dijon exception still exists. METHODS: The population-based stroke registry of Dijon ascertained all first-ever strokes from 2000 to 2006. We calculated incidence to compare recent results with those obtained from a previous study period (1985-1999) and those of other population-based studies covering both the end of the 20th and the beginning of the 21st century. RESULTS: From 2000 to 2006, 1205 strokes were recorded. Crude and age-standardized incidence (to European and World population) rates were respectively 113, 107 and 72/100,000/year. No change was observed between 1985-1999 and 2000-2006, whereas other studies reported declining incidence. CONCLUSION: The incidence of stroke in Dijon remained lower than that found in similar studies, but the difference compared with results observed for the 20th century is shrinking. Therefore, the Dijon exception is decreasing, suggesting that it was rather an advance in prevention strategies that has diminished.

Glycaemic variability is associated with severity of coronary artery disease in patients with poorly controlled type 2 diabetes and acute myocardial infarction.

BACKGROUND: In patients with type 2 diabetes (T2D), glycaemic variability (GV), another component of glycaemic abnormalities, is a novel potentially aggravating factor for coronary artery disease (CAD). OBJECTIVES: The aim of our study was to identify interactions between GV and severity of CAD in diabetes patients admitted for acute myocardial infarction (AMI). METHODS: All patients with T2D admitted to our university hospital for AMI from March 2015 to February 2017 who received intravenous (IV) insulin therapy and underwent coronary angiography were included. GV was assessed by mean amplitude of blood glucose excursion (MAGE) values taken within 2 days of admission. Patients with higher GV (highest MAGE tertile) were compared with those with lower GV (first and second MAGE tertiles). RESULTS: A total of 204 patients were included: median age was 72 (61-81) years; 32% were female; HbA1c was 7.3% (6.4-8.2%); diabetes duration was 10 (2-17.5) years; and MAGE value was 0.65 (0.43-0.92) g/L. Compared with those with lower GV, patients with the highest GV were more often women, treated with previous insulin, and had higher blood glucose and HbA1c levels. In addition, patients with elevated GV had significantly higher SYNTAX scores: 17 (10-28) vs. 12 (6-22) (P = 0.009). Indeed, SYNTAX scores (OR: 1.05, 95% CI: 1.02-1.08; P = 0.001) remained independently associated with high GV beyond HbA1c levels (OR: 1.51, 95% CI: 1.2-1.89; P < 0.001). CONCLUSION: In AMI patients with poorly controlled diabetes, GV is associated with CAD severity beyond chronic hyperglycaemia. Although no causality can be determined from our observational study, the results suggest that, in AMI, early evaluation of GV might contribute to the identification of those diabetes patients at high risk, and serve as a therapeutic target for both primary and secondary prevention.

Plasma N-terminal Pro-Brain Natriuretic Peptide (Nt-proBNP) level and prognosis after myocardial infarction in diabetes.

Plasma N-terminal Pro-Brain Natriuretic Peptide (Nt-proBNP) level has been shown to provide valuable prognostic information on short and long-term mortality in patients with acute Myocardial Infarction, in the general population. Increased plasma Nt-proBNP levels have been found in Type 2 diabetic patients with vascular complications or with hypertension. In a large prospective study performed in 560 patients hospitalized for acute Myocardial Infarction (RICO), we found that median Nt-proBNP levels were significantly higher in the 199 diabetic patients compared to the 361 non-diabetic patients (245 (81-77) vs. 130 (49-199) pmol/L, P<0.0001). This difference remained highly significant after adjustment for confounding factors and we have been able to show that diabetes, per se, was a strong and independent factor for increased plasma Nt-proBNP levels, in this population. In the prospective RICO survey, we have found, in multivariable analysis, that diabetes was an independent factor for in-hospital mortality (OR: 1.79 [1.45-2.20]; P=0.0064) and cardiogenic shock (OR: 1.45(1.22-1.72); P =0.0364) when the variable Nt-proBNP level was not introduced into the model, but was less significantly associated with mortality (OR: 1.73 (1.39-2.16); P=0.0107) and no longer associated with cardiogenic shock when Nt-proBNP was in the model. This data suggest that increased plasma Nt-proBNP may be one of the links between diabetes and poor short-term prognosis after Myocardial Infarction and provides highly valuable prognostic information on in-hospital outcome in diabetic patients.

The Dijon Physical Activity Score: reproducibility and correlations with physical fitness in patients with coronary artery disease.

OBJECTIVES: To study the clinimetric properties of the Dijon Physical Activity Score (PAS) in patients with coronary artery disease (CAD). PATIENTS: Two populations of patients with CAD: one group of stabilized patients from the RICO county-wide monitoring program and one group in the initial phase of a cardiovascular rehabilitation program (CVR group). METHODS: The patients carried out a maximal effort test on a cycle ergometer, plus two walking tests (a six-minute walk test and a 200 m fast walk test). They completed the Dijon PAS questionnaire on two occasions at an interval of 10 days. The reproducibility of the score and the latter's correlations with physical parameters were analyzed. RESULTS: Sixty-seven subjects were included and 52 answered the questionnaire both times. The average time spent answering the questionnaire was 173+/-37 seconds and reproducibility was satisfactory in the RICO group only. In this group, there were significant correlations between total score and maximal power during the effort test (r=0.41; P<0.05) and between the "sports/leisure activities" sub-score and maximal power (r=0.57; P<0.01). No correlations were found in the CVR group. CONCLUSION: The Dijon PAS is a simple, generic, reproducible and reliable score for measuring physical activity in patients with stable coronary artery disease but, because of the conjunction of confounding factors, it is not suitable for subjects who experienced a recent acute cardiac event. It could thus be used in epidemiological studies to determine the impact of a sedentary lifestyle and the efficacy of methods intended to counter sedentariness and to help design personalized secondary prevention programs.

[Long-term management of the stable coronary patient. The optimization of the medical treatment: a real objective]. / Prise en charge au long cours du coronarien stable. L'optimisation du traitement médical : un vrai objectif.

Cardiovascular disease is one of the major causes of early morbidity and death in the developed world, and is becoming a serious public health concern in many developing countries. Over the last 30 years, in the USA and France, coronary angioplasty has become a standard treatment for stable angina, and this despite the recommendations of Learned Societies concerning the treatment of this condition. Today, 85 % of angioplasty procedures are performed on patients with stable angina. This study presents meta-analyses that compare medical treatment with angioplasty, and examine the impact of these strategies on more specific populations such as the elderly and post-myocardial infarction patients. To our minds, this synthesis seems to be of particular importance as the COURAGE study has rekindled the debate by showing that improvements in medical treatment and way of life reduced mortality and the recurrence of MI at five years, whereas there was no positive impact of an invasive strategy in any of the subgroups. Nevertheless, as a whole, studies on this subject underscore the value of angioplasty in the medium term for symptom relief in the case of ineffective medical treatment, notably during an acute coronary syndrome both in patients under medical treatment and in those who underwent invasive therapy at the initial phase.

[Screening and clinical implications of silent atrial fibrillation]. / Dépistage et implications cliniques de la fibrillation atriale silencieuse.

Each year, 5 million new cases of atrial fibrillation (AF) are diagnosed, and the data for the last 20 years show that its incidence has continued to grow. The aging of the population is considered a major explanation for this pandemic phenomenon. The complications associated with atrial arrhythmia are numerous and frequent, with in the first place thromboembolic events. In addition to symptomatic atrial fibrillation, AF may be diagnosed by chance during a systematic ECG, an external Holter or a continuous ECG monitor, or in the memories of implanted cardiac devices. This is called silent AF. Despite numerous studies, silent AF is still largely under-diagnosed and unrecognized in everyday clinical practice, although it is a frequent condition with potentially serious consequences (especially thromboembolic events). Thanks to the development of new diagnostic tools, which are scientifically validated and readily available, the detection of AF has improved significantly, leading to better therapeutic management, in particular anticoagulant therapy. From this perspective, mass screening for silent AF using these new technologies is a major step forward in e-health development. The cost of screening and the heterogeneity of populations affected by silent AF, however, remain major obstacles.

High levels of N-terminal pro B-type natriuretic peptide are associated with ST resolution failure after reperfusion for acute myocardial infarction.

BACKGROUND: B-type natriuretic peptide and the N-terminal fragment of its prohormone, N-terminal pro-brain natriuretic peptide (Nt-proBNP), provide valuable prognostic information on short- and long-term mortality in patients with acute coronary syndrome AIM: To investigate the association between plasma NT-proBNP levels and ST-segment resolution (STR) after reperfusion in patients with ST-segment elevation myocardial infarction (STEMI). METHODS: Consecutive patients from the French regional RICO survey with STEMI who were treated by primary PCI or lysis <12 h were included. Blood sample was taken on admission to measure plasma NT-proBNP. Maximal ST segment elevation was measured on the single worst ECG lead before and 90 min after reperfusion. Patients were categorized as STR(-) (<50% STR) or STR(+) (>or=50% STR). RESULTS: Of the 486 patients included, 133 (27%) were STR(-). STR(-) patients had similar cardiovascular risk factors but higher in-hospital mortality (5% vs. 1%, p=0.03) than STR(+) patients. The STR(-) group had higher median (IQR) levels of Nt-proBNP: 938 (211-3272) vs. 533 (169-1471) pg/ml, p=0.003. On multivariate analysis, the highest quartile of Nt-ProBNP, Q waves and lysis were independent risk factors for incomplete STR. DISCUSSION: Our data show a strong association between high levels of Nt-proBNP at admission and incomplete STR, suggesting that Nt-proBNP may be useful for early risk stratification in reperfusion therapy after acute myocardial infarction.

[The best of epidemiology and cardiovascular prevention in 2006]. / L'essentiel de 2006 en épidemiologie et prévention cardiovasculaire.

The recent analysis of the French MONICA registries report a reduction in the incidence of fatal MI related to improvement of care whereas the overall incidence of coronary events remain stable, suggesting the need for a better primary prevention. The extensive review of the death certificates and the analysis of the death classification from the same registries indicate an under estimation of MI-related death in the national death registry. It is also confirmed that instead of 50%, approximately 80% of coronary death are explained by the four major risk factors including smoking, hypercholesterolemia, hypertension and diabetes. The international REACH registry has enrolled more than 67 000 individuals including patients with symptomatic atherothrombotic disease and patients with multiple risk factors. The analysis of baseline characteristics and of the one year FU shows a high residual risk and a lack of efficacy of secondary prevention. The existence of a symptomatic disease and the number of symptomatic localization of atherothrombosis are critical factors to predict recurrence of major vascular events Secondary analysis of the INTERHEART study provide the essence of what should any physician know about the relationship between coronary heart disease and smoking, either active or passive. Prevention with respect to this risk factor remains very insufficient. Varenicline, a new nicotinic receptor partial agonist, should help patients involved in smoking cessation program. The established detrimental effects of perioperative smoking represent a unique opportunity to promote smoking cessation in individuals scheduled for surgery. The major cardiovascular impact of second hand smoking has been recently demonstrated by the short-term effects of banning smoking in public places on the incidence of acute coronary events. The SPARCL study has demonstrated the benefit of high dose of atorvastatine to prevent recurrent acute ischemic cerebrovascular event in patients with a prior history of stroke or TIA. In the open ASTEROID study, high doses of rosuvastatine confirm the possibility of reducing the volume of coronary atheroma analyzed by IVUS. The expected benefit of glitazones to reduce the incidence of death, MI and stroke in diabetes patients with a prior history of vascular event has been confirmed in the PROactive study. Pioglitazone provided a clear reduction of recurrent vascular events in diabetes patient with a prior MI at a cost of a significant increase of the risk of heart failure. In the DREAM study, neither ramipril nor rosiglitazone have reduced the incidence of cardiovascular events significantly. The moderate benefit of the fenofibrate to prevent cardiovascular events in the FIELD study, which was carried out in diabetics mostly in primary prevention, needs to be considered after adjustment on statin use in a higher proportion of patients of the placebo group. Postprandial hyperglycaemia, analyzed by the peak of glycaemia after a load in glucose, has been confirmed as a more powerful independent predictive factor of the risk of cardiovascular event than fasting glycaemia. The systematic screening postprandial hyperglycaemia represents an interesting strategy for primary prevention which warrants further investigation. If obesity is a risk factor whose impact on morbi-mortality is well established, a French study shows that body mass index has an unfavourable influence on the cognitive functions in middle-aged men and women.

[Epidemiology of acute coronary syndrome in Europe]. / Epidémiologie du syndrome coronaire aigu en Europe.

Epidemiological data concerning acute coronary syndromes in Europe are based on national registries, studies by the European Society of Cardiology within the framework of the EuroHeart Survey and on the study of European population sub-groups in large international cohorts. In this article, recently published studies will be reviewed, and the principal developments in different countries as well as the characteristics and particularities of the most recent epidemiological data will be highlighted. In Europe, the presentation of acute coronary syndromes (ACS) has evolved considerably over the last ten years. This evolution is characterized by a reduction in the proportion of acute coronary syndromes with ST-segment elevation (STEMI) and by ageing populations.

[Long-term management of post acute coronary syndrome with oral antiplatelet therapy]. / Prise en charge au long cours par les anti-agrégants plaquettaires oraux après un syndrome coronaire aigu.

Cardiovascular disease is the primary cause of early death and morbidity in the industrialized world and is becoming a growing problem in many developing countries. Coagulation inhibitors play a major role in the management of the acute phase of ACS whether in association with reperfusion strategies or not. Currently, and in accordance with the results of major randomised studies, for medium and long-term management, the association of Clopidogrel and aspirin is the treatment of choice. However, despite the recognised benefits of this therapeutic strategy and above all the recommendations of learned societies, which have placed this bi-therapy in class I, according to national and international registries it is still underused. Moreover, all of these registries have confirmed, in the real world, the negative impact of not prescribing this antiplatelet therapy on morbidity and mortality after both ST and non-ST elevation acute coronary syndrome. which shows the difficulty of applying to everyday clinical practice the results of major randomised cohorts.

[Relationship between coronary artery disease and periodontal disease. What the cardiologist must know]. / Relations entre les pathologies cardiovasculaires et buccodentaires. Ce que le cardiologue doit connaître.

In this review, we will present the recent works, which shows a link between arterial lesions, particularly in coronary arteries, and periodontal disease. The pathways are those of chronic infection, and several studies have revealed a relationship between arterial lesions and buccal bacteraemia. Though the mechanism that links them is still unclear, the first hypotheses suggest that the presence of the bacteria in the bloodstream triggers a direct reaction (bacteria on the target organ), and/or an indirect immune reaction. This immune response could be induced by an increase in the secretion of pro-inflammatory cytokines (IL1, IL6, TNF), which are also involved in atherogenesis. Indeed, these cytokines have been found in higher concentrations in patients with periodontal disease, whereas reduced levels have been found in patients who have had deep gum pockets thoroughly cleaned. Cardiologists need to have access to such information not only because of the similarity of the populations, but also because of the therapeutic consequences. The future development of simple dental scores will provide an important tool for epidemiological studies of primary and secondary prevention.

[Infarction in the per-operative period: check-up, results, treatment, surveillance]. / Infarctus et période péri-opératoire: quel bilan? Quel traitement? Quelle surveillance?

Peroperative infarction (POI) is a frequent and serious event, which is associated with an increase in morbidity and mortality; the risk is aggravated to varying degrees by the techniques of anaesthesia and surgery used. The preoperative evaluation of risk, which combines clinical and paraclinical criteria is described in the algorithm of the new AHA/ACC guidelines. In order to avert these ischemic episodes, beta-blockers must be continued or introduced during vascular surgery. In other types of surgery, they must be considered. It is difficult to diagnose MI in a per-operative context. The electrocardiogram print out and troponin kinetics will identify patients in the postoperative phase that should be oriented towards cardiovascular evaluation and therapy.