Silent myocardial ischemia in patients with diabetes: who to screen.

OBJECTIVE: Silent myocardial ischemia (SMI) is more common in diabetic patients than in the general population. However, the exact prevalence of SMI is not known, and routine screening is costly. The purpose of this 1-year study was to estimate the prevalence of SMI and define a high-risk diabetic population by systematically testing patients with no symptoms of coronary artery disease (CAD). RESEARCH DESIGN AND METHODS: The criteria for inclusion in this study were age (between 25 and 75 years), duration of diabetes (>15 years for type 1 diabetes, 10 years for type 2 diabetes with no cardiovascular risk factors, and 5 years for type 2 diabetes with at least one cardiovascular risk factor), and absence of clinical or electrocardiogram (ECG) symptoms of CAD. For 1 year, 203 patients were screened, including 28 women and 45 men with type 1 diabetes (aged 41.5+/-10.9 years, mean duration of diabetes 20.9+/-7.7 years [mean +/- SD]) and 61 women and 69 men with type 2 diabetes (aged 60.7+/-8.7 years, duration of diabetes 16.5+/-7.1 years). Exercise ECG was the first choice for screening method. If exercise ECG was not possible or inconclusive, thallium myocardial scintigraphy (TMS) with exercise testing and/or dipyridamole injection was performed. If any one of these tests was positive, coronary angiography was carried out and was considered to be positive with a stenosis of > or =50%. RESULTS: Positive screening results were obtained in 32 patients (15.7%). Coronary angiography demonstrated significant lesions in 19 patients (9.3%) and nonsignificant lesions in 7 patients (1 false-positive result for exercise ECG and 6 false-positive results for TMS). Coronary angiography was not performed in six patients. All but 3 of the 19 patients (15 men and 4 women) in whom silent coronary lesions were detected presented with type 2 diabetes. The main differences between the 16 type 2 diabetic patients presenting with coronary lesions and the type 2 diabetic patients without SMI were a higher prevalence of peripheral macroangiopathy (56.2 vs. 15.1%, respectively, P < 0.01) and a higher prevalence of retinopathy (P < 0.05). No correlation was found between SMI and duration of diabetes, HbA1c level, renal status, or cardiovascular risk factors except for family history of CAD. CONCLUSIONS: The results of this study allowed us to determine a high-risk group for SMI in the diabetic population. SMI with significant lesions occurs in 20.9% of type 2 diabetic male patients who are totally asymptomatic for CAD. Based on these findings, we recommend routine screening for male patients in whom the duration of type 2 diabetes is >10 years or even less when more than one cardiovascular risk factor is present.

Genetic polymorphisms and coronary artery disease in the south of France.

Vascular disease is a multifactorial disease that involves atherosclerotic and thrombotic factors. Genetic polymorphisms have been associated with myocardial infarction and angina pectoris. The aim of the present study was to assess the relationship between some genetic polymorphisms and myocardial infarction (MI) or vasospastic angina pectoris in a population from southern France. Genetic polymorphisms of the renin angiotensin system (the D/I polymorphism of the ACE gene and the A1166C polymorphism of the angiotensin II type 1 receptor [AT1R]) and of haemostatic factors (the -675 4G/5G polymorphism of the plasminogen-activator inhibitor 1[PAI-1] gene, and the G to T common point mutation in exon 2, codon 34 of the Factor XIII A-subunit gene) were examined. We assessed the genotype distribution in consecutive coronary artery disease (CAD) patients with MI (n = 201) and vasospastic angina pectoris (n = 43) and in 244 healthy controls comparable in age, sex, body mass index and total cholesterol level. The genotype distribution of AT1R polymorphism was significantly different between controls and patients, the prevalence of the C allele carriers being higher in patients with MI after the age of 45 than in control individuals (61 vs 45%, p <0.01), leading to an odds ratio (OR) of 2 (CI: 1.2-3.4). When looking at the group of patients with vasospastic angina the difference was even higher (76 vs 45%, p <0.01) yielding an OR of 4.3 (CI: 1.4-17.4). Genotype distributions of ACE, PAI-1 and Factor XIII polymorphisms were similar in patients and in controls. This study is in favor of a role of ATIR gene polymorphism in myocardial infarction and vasospastic angina.

Methergin testing with angiographically normal coronary arteries.

To evaluate the incidence of spasm in patients with angiographically normal coronary arteries or with stenosis less than or equal to 50%, methergin testing was done consecutively in 1,200 patients (742 men and 458 women). The methergin test was performed 850 times during coronary angiography and 350 times after it. The test was globally positive in 11% (127 of 1,200 patients), positive in 7% among 921 patients presenting with atypical chest pain, 13% of 31 patients with effort angina, 54% of 54 with angina at rest, 57% of 53 with Prinzmetal's angina, 3% of 59 with acute myocardial infarction and 1% of 82 miscellaneous patients without chest pain. Another test was done in 291 patients after blockade of the cardiac autonomous nervous system with 0.04 mg/kg of atropine and 2 mg/kg of labetolol. The frequency of positive results in the methergin test increased after blockade from 8 to 19% (p less than 0.01). The increase of positive results was especially obvious among patients with atypical chest pain (from 6 to 14%). Thus, frequency of spasm in these patients with normal coronary arteries or without significative lesions was 11%. This incidence was influenced by the composition of the patient population and increased with blockade of the cardiac autonomous nervous system.

Comparison of treatment with lisinopril versus enalapril for congestive heart failure.

The effect of lisinopril 5-20 mg once daily or enalapril 5-20 mg once daily on exercise capacity, ventricular ectopic activity, and signs and symptoms of heart failure have been studied in 278 patients with mild-to-moderate (New York Heart Association [NYHA] classes II and III) heart failure in a randomized, double-blind, parallel-group study of 12 weeks' duration. Exercise duration was significantly increased by both angiotensin-converting enzyme (ACE) inhibitors after 6 and 12 weeks of treatment compared with their respective baseline values. There was a trend toward a greater increase in exercise duration on lisinopril after 12 weeks, although this did not reach statistical significance (p = 0.0748). There were no significant treatment differences with respect to the effect of the 2 drugs on ventricular ectopic counts, couplets, or nonsustained ventricular tachycardia. Both drugs were equally effective in improving NYHA grading and symptoms. Neither treatment had any significant effect on mean heart rate or mean blood pressures. Both treatments were equally well tolerated. The most commonly reported adverse events on both drugs were cough, dizziness, fall in blood pressure, vertigo, and myocardial infarction. The results of this study indicate that lisinopril 5-20 mg once daily is at least as effective and well tolerated as enalapril 5-20 mg once daily.

1H nuclear magnetic resonance and clinical studies of interaction of calcium antagonists and hypoglycemic sulfonylureas.

The hypoglycemic effect of gliclazide is mainly due to its action on ATP stimulated K+ channels, but the calcium ionophoretic effect of this drug may also be involved in its physiological properties. Using 1H NMR we demonstrated the antiionophoretic effect of nifedipine and diltiazem. We attempted to verify whether this in vitro interaction also occurs in vivo. A clinical trial, was performed on patients treated concomitantly with gliclazide and nifedipine or diltiazem. Results showed that no in vivo interaction occurred. The discrepancy between in vivo and in vitro results may be explained by a too weak plasma concentration in the case of nifedipine and by a large plasma protein binding in the case of diltiazem.

Clinical electrophysiologic effects of a single high oral dose of amiodarone.

Several recent reports have described the antiarrhythmic effects of a single high oral dose of amiodarone but clinical electrophysiologic effects have not been reported. The present study was performed to assess electrophysiologic effects in 12 patients. After baseline electrophysiologic studies (EPS) patients were administered a single oral dose of 30 mg/kg of amiodarone. EPS was repeated 7.5 +/- 0.5 hours later. Plasma levels of amiodarone and its metabolite desethylamiodarone were determined at the time of the second EPS, Holter monitoring was performed for 24 hours after amiodarone administration. Amiodarone significantly increased the following parameters: corrected QT interval (+4.5%), functional refractory period of the right atrium (+7%); AH interval (+12.3%), effective refractory period of the atrioventricular node (+18.5%), and cycle length of Wenckebach block (+8.4%). These effects were not correlated with plasma levels of amiodarone and desethylamiodarone. Holter monitoring detected no significant bradycardia or arrhythmia. These findings indicate that the effects of a single high oral dose of amiodarone are the same as those known to be induced by acute intravenous administration.

Cardioprotective effect of intracoronary nifedipine during percutaneous transluminal coronary angioplasty. A French double-blind cross-over multicentre study.

The aim of this double-blind, placebo-controlled, cross-over study was to assess the cardioprotective effect of intracoronary nifedipine during percutaneous transluminal coronary angioplasty balloon occlusion. A balloon inflation without drug injection was initially made to ascertain that a shift of the ST segment (> or = 2 mm, 0.08 s after the J point) appeared (inclusion criterion). Two other balloon inflations were preceded by intracoronary injection of either 0.2 mg nifedipine or placebo, distal to the stenosis through the balloon catheter. The evaluation criteria were (1) time to ST segment shift, and (2) maximal amplitude of ST segment shift caused by balloon occlusion. Comparison of the data used an analysis of variance. Sixty-seven patients (mean age 54 +/- 8 years; 54 male, 13 female) were studied; 50 patients had 1-, 16 patients 2- and 1 patient 3-vessel disease. The dilated vessel was the left anterior descending coronary artery (n = 51), the right coronary artery (n = 12) and the left circumflex coronary artery (n = 4). Balloon inflation time was 100 +/- 31 s in the nifedipine group and 93 +/- 29 s in the placebo group. Five patients were excluded (procedure stopped after the first inflation in 1 and ST segment shift < 2 mm during the first inflation in 4). The time to 2-mm ST segment shift was longer in the nifedipine group than in the placebo group (62 +/- 40 s versus 51 +/- 40 s, P < 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

Treatment of venous thrombosis and pulmonary embolism by streptokinase.

We applied the standard treatment with streptokinase to 52 cases of deep venous thrombosis and 35 cases pulmonary embolism. Angiography demonstrated total lysis of the clot 22 times, partial lysis 42 times, and no lysis 23 times. The absence of lysis was more frequent in venous clots than in pulmonary clots. Early treatment was more effective, achieving complete lysis in 21 of 22 cases. Nevertheless, in deep venous thrombosis, late treatment can result in partial lysis and set an important venous junction free. With the standard treatment, the biologic controls showed good lysis in 75% of the cases, insufficient lysis in 15%, and no lysis in 10%. The extent of the thrombosis is an important point. The clot was totally lysed in 9 of 10 cases of localized deep venous thrombosis. In patients with pulmonary embolism, about 30% of the obstructed surface is cleared. Nevertheless, in such cases we must take into consideration not only the nonperfused pulmonary area, but also the venous starting point of the clot.

[Does syndrome X exist?]. / Le syndrome X existe-t-il?

The syndrome X is an entity characterised by the association of chest pain on exercise and a positive exercise stress test in patients with normal coronary angiography. However, this diagnosis can only be admitted when all other causes of angina with normal coronary arteries have been excluded. They include angina secondary to coronary artery spasm and myocardial hypertrophy. A review of the literature based on 26 publications recensing 822 patients shows that these criteria are not always respected: a really positive exercise stress test is an inclusion criterion in only 13 studies and concerns only 313 patients (38.1%); myocardial hypertrophy and coronary spasm were formally excluded in only 278 (33.3%) and 228 patients (27.7%) respectively. Taking into consideration only the patients of these 26 series with a positive exercise stress test after exclusion of coronary spasm and myocardial hypertrophy, 143 (17.4%) may be considered to be due to syndrome X. Syndrome X is a real entity but its incidence is usually overestimated. It is appropriate to distinguish it from other conditions associating, though the exercise stress test is negative, chest pain on effort and the positivity of a test considered to be indicative of myocardial ischaemia.

[Does diabetes change the anti-ischemic therapeutic options in the symptomatic coronary patient?]. / Le diabète modifie-t-il le choix des thérapeutiques anti-ischémiques chez le coronarien symptomatique?

The assessment of results of medical treatment, angioplasty and coronary bypass surgery in diabetic coronary patients is difficult because of the absence of distinction in the subgroups of type 1 and 2 diabetes and of stable and unstable angina. With respect to medical therapy, betablockers are practically without deleterious effects and are effective in diabetic populations. The same is true of other antianginal drugs. Conventional coronary angioplasty is associated with poorer results than the general population in the long-term, partly because of progression of the coronary artery disease and partly because of an increased incidence of restenosis. The use of stents improves these results, which are similar to those of the general population with single vessel disease or those without proteinuria. Coronary bypass surgery, despite a certain perioperative morbidity, is associated with an identical survival rate at 5 years as non-diabetics, providing the internal mammary artery is grafted. The comparison between these methods is resumed in the ACIP study which opposes the 3 strategies, in Morris et al's study comparing medical and surgical approaches and, finally, in the recent BARI trial where patients were randomly allocated to angioplasty or surgery. It would appear that the surgical strategy gives better results in multivessel disease. However, many reserves have been voiced because of the small numbers of patients, the high number of excluded patients and the fact that recent progress in angioplasty with widespread use of stenting associated with the prescription of new antiaggregant drugs was not taken into account.

[Thrombolytic therapy of myocardial infarction: practical management]. / Traitement thrombolytique de l'infarctus du myocarde: réalisation pratique.

Myocardial infarction (MI) is the result of acute coronary occlusion and the prognosis depends on the infarct size. In experimental studies, infarct size is reduced by early coronary reperfusion which may be obtained by intravenous thrombolytic therapy. This simple, rapid and widely used technique is the clinical treatment of choice. The diagnosis of MI must be confirmed by clinical and electrocardiographic findings. The clinical history is important because the value of reperfusion when started after the 6th hour after the onset of chest pain is questionable. However, it is often difficult to determine the beginning of MI when preceded by unstable angina. Contraindications to thrombolytic therapy must be carefully excluded irrespective of the thrombolytic agent because of the risk of haemorrhage. This must be weighed up against the risk of the MI itself. Therefore, age is not a systematic exclusion criterion. The choice of thrombolytic is based on the efficacy, mode of administration and cost. Heparin therapy at effective doses is associated in all cases to prevent reocclusion. Aspirin is given orally. The association of a calcium inhibitor or a betablocker may also be considered. Reperfusion and ischaemia may give rise to arrhythmias and haemodynamic changes which have to be rapidly corrected. Haemorrhagic complications during thrombolysis are treated according to the severity and time of onset by blood transfusion sometimes associated with a plasmin inhibitor. Reocclusion is an indication for emergency coronary angioplasty but in some cases repeat thrombolytic therapy may be beneficial. When the MI is extensive, rapid transfer to a cardiological centre with catheter facilities is advisable.(ABSTRACT TRUNCATED AT 250 WORDS)

[Provocation tests for coronary spasm. Methods, value and indications]. / Les tests de provocation du spasme coronarien. Méthodes, valeur et indications.

Five methods are currently used to demonstrate coronary spasm: they use derivatives of ergotamine, alkalinisation, cold, adenosine triphosphate and exercise stress test. The criteria used to confirm spasm are either direct visualisation at coronary angiography or indirect electrocardiographic changes. The value of these test is beginning to be established: --their specificity is excellent with all methods (a positive test is diagnostic); --their sensitivity is mediocre (a negative test does not exclude the diagnosis). This depends on three factors: the choice of criteria of positivity: angiographic appearances is the most reliable; the timing of the test: it is more likely to be positive when the test is carried out close to episodes of chest pain; the method of provocation: the most sensitive tests use either the ergotamine derivatives or alkalinisation; --reproductibility is satisfactory at short and long term. These tests have diagnostic and therapeutic indications. It is preferable to perform diagnostic tests during coronary angiography in patients with normal coronary arteries and unexplained episodes of chest pain. However, in patients with fixed coronary lesions (except triple vessel and left main stem disease) when coronary bypass surgery is planned, the results of the test can help in the choice of associated therapy, such as plexectomy and calcium antagonist drugs. The repetition of the test is useful in the evaluation of antispastic therapy: when the test becomes negative the drug used is probably effective. In conclusion, with equal patient comfort and MSR, provocation tests using the ergotamine derivatives would seem to be the method of choice: alkalinisation is a good alternative.

[Thrombolysis in the pre-hospitalization phase of myocardial infarction]. / La thrombolyse à la phase préhospitalière de l'infarctus du myocarde.

In myocardial infarction (MI), the sooner thrombolysis is performed, the greater the chances of it being effective. We report a 19-month experience (July 1, 1986 to December 31, 1987) of thrombolysis performed at home prior to hospitalization by an organization called SOS Myocardial Infarction (SOS MI). Method. Throughout 24 hours, any patient may call by telephone a doctor attached to SAMU 13. If the doctor suspects a coronary emergency, he sends to the patient's home the SOS MI team (1 doctor and 1 nurse) in a medically-equipped ambulance. The diagnosis of MI is made on the finding of a nitroglycerin-resistant chest pain of more than 30 minutes duration associated with a more than 2 mm elevation of the ST segment on at least two electrocardiographic leads. Patients aged under 70 and in whom thrombolytic drugs are not contra-indicated are then treated intravenously with either streptokinase (1.5 million units over 30 min) or the tissue plasmogen activator (10 mg followed by a 90 mg infusion over 90 min). Results. During the 19-month period, 648 coronary emergencies were suspected from data given by telephone. The diagnosis made by the SOS MI doctor was non-coronary chest pain in 119 cases (18.4 p. 100), angina pectoris in 211 cases (32.6 p. 100).(ABSTRACT TRUNCATED AT 250 WORDS)

[Chemical blockade of the cardiac autonomic nervous system. Effects on the coronary arterial vasomotor activity]. / Blocage chimique du systéme nerveux autonome cardiaque. Effets sur la vasomotricité artérielle coronaire.

The results of cardiac plexectomy in spastic angina are controversial. This study was undertaken to evaluate the effects of blocking the cardiac autonomic nervous system (CANS) in this syndrome in 61 patients presenting with chest pain and angiographically normal coronary arteries. All patients underwent a methyl-ergometrine provocation test with a sequential protocol. They were then divided into two groups: Group 1 (13 patients): positive response to ergometrine. Group 2 (48 patients): negative response to ergometrine. Three sub-groups were identified: 2: 1: 9 patients with coronary spasm demonstrated by another method: 2: 2: 6 patients with myocardial infarction: 2: 3: 33 patients with chest pain alone. The results of these tests were compared with those obtained after blocking the CANS by intravenous injection over 3 minutes of an alpha and beta-blocker (labetalol 2 mg/kg) and a parasympathetic blocker (Atropine. 0.04 mg/kg). The CANS blockade was confirmed by two facts: the basal heart rate of 66.38 +/- 9.91 rose to ots intrinsic rate of 89.76 +/- 10.5 (p less than 0.01) and remained at that rate after ergometrine and trinitrate administration and myocardial ischaemia; changes in blood pressure were greater after CANS blockade: + 30.62 +/- 16.13 mmHg instead of + 8.62 +/- 0.33 mmHg after ergometrine (p less than 0.01) and -43.16 +/- 16.32 mmHg instead of -25.16 +/- 3.64 mmHg after trinitrate (p less than 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)

[Repeated coronarographies in 122 medically treated patients]. / Coronarographies itératives chez 122 patients traités médicalement.

122 patients treated medically 115 men and 7 women aged 51.9 +/- 8.51 years (range 32 to 79 years) underwent repeat coronary angiography 34 +/- 26 months (1 month-11 years) after the initial investigation Patients with normal coronary arteries were excluded. The repeat investigation was performed for aggravation and persistance of symptoms in 74 cases, myocardial infarction in 14 cases, with a view to aortocoronary bypass in 23 cases, for cardiac failure in 8 cases and for ventricular arrhythmias in 3 cases. Three groups of patients could be distinguished: Group I: the coronary angiography was unchanged (41 patients, 33.6 p. 100). The interval between the two investigations was 30.7 +/- 24.8 months. Group II: the coronary lesions had regressed in 12 patients (9.8 p. 100). The interval between the two investigations was 29.4 +/- 23 months. The degree of stenosis was reduced in 6 cases; recanalisation of an occluded artery was demonstrated in 3 cases; coronary spasm was diagnosed in 3 cases. Paradoxically, 4 patients had developed lesions on other coronary segments. Group III: the coronary lesions had progressed in 69 patients (56.6 p. 100). The interval between the two investigations was 36.8 +/- 26.9 months. The progression was observed on a pre-existing stenosis in 51 cases and on an initially normal segment in 34 cases. Left ventricular function had worsened in 21.7 p. 100 of patients compared to only 5.6 p. 100 of patients in groups I and II (p less than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

[False pseudoaneurysm of the left ventricle after myocardial infarction. Recognition by transesophageal echocardiography]. / Pseudo-faux anévrysme du ventricule gauche après infarctus du myocarde. Reconnaissance par l'échocardiographie transoesophagienne.

Left ventricular pseudo-false aneurysm is caused by a discrete rupture of the myocardial wall which remains circumscribed within the wall itself, realising a cavity joined to the left ventricle by a narrow neck. It is an extremely rare complication of myocardial infarction. Two cases diagnosed in vivo by left ventriculography are reported. Their diagnosis and precise locations were confirmed by transoesophageal echocardiography. In the first case, the pseudo-false aneurysm was situated in the interventricular septum and, in the second, in the antero-lateral wall. The natural history of asymptomatic pseudo-false aneurysms is unknown. The advanced age of the patients and the possibility of regular follow-up by transoesophageal echocardiography were the main reasons for surgical abstention in these particular cases.

[Ergometrine test in 1200 consecutive patients presenting with normal coronary vessels]. / Le test à l'ergométrine chez 1,200 malades consécutifs présentant des coronaires normales.

An ergonovine test (ET) was performed in 1,200 patients-742 men, 458 women aged from 34 to 73 years (mean: 49.5 years)-either during (850 cases) or after (350 cases) coronary arteriography. Another ET made more sensitive by blocking the cardiac autonomous nervous system (CANS) with labetalol 0.04 and 2 mg/kg was performed in 291 of these patients. The ET test was positive in 10.7 p. 100 (127) of all patients and in 11.2 p. 100 (127/1125) of patients presenting with retrosternal pain. In the group where spontaneous angina could be confirmed by ECG recordings during the attack, the percentage of positive responses rose significantly to 53.7 p. 100 patients with ST depression and 56.6 p. 100 of patients with ST elevation. When the anginal nature of the retrosternal pain was not confirmed before the test, the proportion of positive responses was 6.6 p. 100. In patients who had the sensitized test the positive response rate increased in all groups and globally rose significantly from 7.9 p. 100 to 18.6 p. 100 (p less than 0.01). Thus, the usually low frequency of positive ergonovine tests differs according to the population selected and increases after CANS blockade.

[Pure coronary spasm: autonomic disease or form of onset of atheroma? Contribution of repeat coronarography in 23 patients]. / Angor spastique pur: maladie autonome ou forme de début de l'athérome? Apport de la coronarographie répétée chez 23 malades.

Coronary spasm has often been blamed for facilitating the development of atheroma, but some authors regard it as a separate disease. In order to form an opinion on these two theories, we performed repeat coronary arteriography at an interval of 4 years on average in 23 patients: 19 men and 4 women aged from 38 to 62 years (mean: 49,4 years). At the initial examination the coronary vessels were normal in 11 patients and showed irregular arterial walls without significant stenosis in 12 patients. Coronary spasm was demonstrated directly in 17 cases (6 spontaneous spasms during arteriography and 11 induced spasms) and indirectly in 6 cases (ECG signs of ischaemia during the anginal attack). At the second coronary arteriography we found that the spasms persisted, with positive response to a challenge test in 17 out of the 19 patients tested. The challenge test was not performed in 4 patients who had developed significant lesions. The vessels themselves were altered in 6 patients, with images of occlusion (2 cases), stenosis (2 cases), parietal irregularities (1 case) and aneurysm (1 case) appearing on spastic arteries, and images of stenosis in 2 patients with apparently non-spastic arteries. There was no difference in age, sex, risk factors, initial coronary status and time interval between arteriographies between these 6 patients and the 17 patients whose coronary arteries had remained unchanged.(ABSTRACT TRUNCATED AT 250 WORDS)

[A combination of nifedipine and diltiazem in the treatment of refractory spastic angina]. / Association de la nifédipine et du diltiazem dans le traitement de l'angor spastique réfractaire.

Both diltiazem (D) and nifedipine (N) have been shown to be effective in the treatment of spastic angina, but they sometimes prove inadequate, even in high doses. These two drugs have been given in combination on the grounds of a possible synergistic action, but the results obtained were limited by side-effects. We decided to administer the combined treatment in half doses to patients with spastic angina and normal coronary vessels in order to assess its effectiveness and acceptance. The trial was conducted on 13 patients: 11 men and 2 women aged from 37 to 71 years (mean 53 years) with normal or subnormal coronary arteriography. In the absence of any treatment, these patients responded to the ergonovine test by a coronary spasm which we were subsequently unable to prevent with either D or N. Each patient underwent, at the same hours, 4 ergonovine tests, the product being injected intravenously every 3 minutes in incremental doses of 1, 2, 3 and 6 micrograms/kg. These tests were performed without treatment, after 3 days of treatments with D alone (360 mg/kg), after 3 days of treatment with N alone (60 mg/kg) and after 3 days of treatment with D (180 mg/kg) plus N (30 mg/kg). Without treatment, ergonovine triggered the coronary spasm in all 13 patients at a mean threshold dose of 2.7 micrograms/kg. Under treatment with D or N given separately, no test became negative, but the threshold doses of ergonovine rose to 4.5 and 4.6 micrograms/kg respectively (p less than 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)

[Treatment of coronary restenosis by repeated coronary transluminal angioplasty. Immediate and medium-term results]. / Traitement de la resténose coronaire par une nouvelle angioplastie coronaire transluminale. Résultats immédiats et à moyen terme.

To assess the immediate and medium term efficacy of percutaneous transluminal coronary angioplasty (PTCA) for restenosis, we retrospectively studied 102 patients undergoing a second PTCA between August 1983 and October 1987. The patients were 89 males and 13 females, mean age 61 +/- 7 years. Before the second PTCA, 13 patients were asymptomatic, 31 had effort angina and 58 resting angina. Exercise stress test performed in 50 patients was positive in 40 cases, negative in 9 and uninterpretable in 1. The coronary lesions were: 59 one vessel disease (58 p. 100) and 43 multivessel disease in which PTCA was performed on 1 lesion in 40 and on 2 lesions in 3. Primary success of PTCA was obtained in 100 patients (98 p. 100); 2 patients underwent coronary artery bypass graft (CABG), 1 as an emergency. At 6 months 45 patients had recurrent chest pain (46 p. 100) and 52 were asymptomatic. Control coronary angiogram performed in 70 patients (72 p. 100) after a mean delay of 7.4 +/- 6 months showed a second restenosis in 34, symptomatic in 31. Medium term follow-up was obtained for 96 patients (96 p. 100) with a mean follow-up period of 22.3 +/- 13.2 months. There were 5 cardiac deaths (5.2 p. 100) and 4 non fatal myocardial infarctions (4.2 p. 100). A new revascularization procedure after the second PTCA was performed in 33 patients (34.4 p. 100). Twenty-five patients underwent a third PTCA (26 p. 100), 5 patients a fourth PTCA (5.2 p. 100) and 11 patients underwent a CABG (11.4 p. 100).(ABSTRACT TRUNCATED AT 250 WORDS)