[Coordinated management of arterial hypertension]. / Prise en charge coordonnée de l'hypertension artérielle entre le praticien et les spécialistes - Place de la dénervation rénale dans l'HTA résistante.

Despite major therapeutic progress and the numerous poly-pill combinations available on the market today, the control of arterial hypertension remains widely insufficient. A multidisciplinary management putting together internal medicine, nephrology and cardiology specialist offers the best chances for patients to achieve their blood pressure goals, especially when suffering from resistant hypertension despite adequate prescription of the reference tri therapy: ACEI/ARA2 combined with a thiazide-like diuretic and calcium channel blocker. Recent studies and randomized trials from the last five years shed a new light on the value of renal denervation and its efficacy on lowering blood pressure. This will probably lead to the integration of this technique in the next guidelines and improve its adoption over the next years.

Malgré les progrès thérapeutiques et les nombreuses combinaisons médicamenteuses de type « pilule combinée ¼ disponibles de nos jours, le contrôle de l'hypertension artérielle reste insuffisant. Une prise en charge multidisciplinaire reliant la médecine générale, la néphrologie et la cardiologie offre les meilleures chances aux patients de maîtriser leur hypertension artérielle, notamment en cas de résistance à la trithérapie de référence IECA/ARA2, inhibiteur calcique et diurétique de type thiazidique. Dans l'arsenal thérapeutique actuel, la dénervation rénale mérite à nouveau une attention particulière grâce aux avancées de la technique et aux résultats encourageants des études récentes, ouvrant le chemin à son intégration dans les prochaines recommandations internationales.

[Cardio-oncological risk stratification and follow up: a new challenge for the general practitioner]. / Prise en charge cardio-oncologique : un nouveau défi pour le praticien.

Rise of medical oncology, aging of populations and survival rates' improvement of patients suffering from cancer are all factors contributing to exponential rise of the exposure of patients to -cardiotoxic therapies. A multidisciplinary approach including a close cooperation between general practitioner and specialists will -promote an early identification and treatment of cardiovascular complications related to cancer treatments. This strategy has proven to have a truly positive impact on both cardiovascular and onco-logic prognosis. We will summarize throughout this article the last recommendations established by the European Society of Cardiology in terms of cardiovascular risk stratification and follow up planning through the use of clinical, biological and cardiac imaging data.

L'essor de l'oncologie médicale, le vieillissement des populations et l'amélioration de la survie des patients atteints de cancer sont autant de variables qui expliquent l'exposition grandissante à des thérapies anticancéreuses potentiellement cardiotoxiques. Une approche multidisciplinaire entre le médecin de première ligne et les différents spécialistes permettra de prévenir et de repérer ­précocement les complications cardiovasculaires liées aux traitements, avec un impact réel sur le pronostic oncologique et cardiovasculaire. Nous résumons dans cet article les dernières recommandations de la Société européenne de cardiologie en matière de stratification du risque cardiovasculaire à travers l'utilisation de données cliniques, biologiques et de l'imagerie cardiaque.

[The influence of summer temperatures on the incidence of Takotsubo cardiomyopathy : a retrospective study]. / Influence des canicules sur l'incidence du syndrome de Takotsubo : étude rétrospective en Valais.

Takotsubo cardiomyopathy (TK-CM) is a reversible acute left ventricular dysfunction that cannot be explained by an obstructive coronary lesion. The aim of our study was to explore the possible correlation between the incidence of TK-CM in summer and the average temperature, number of heat waves or number of days hotter than 30°C. 482 patients presented an acute coronary syndrome in the summers of 2012 until 2017 in our region. 15 patients met the inclusion and exclusion criteria and were diagnosed as TK-CM. The study analysis showed a statistically correlation between the number of heatwaves and the incidence of TK-CM (coefficient of correlation: 0.77; p = 0.04). This comforts the hypothesis of climatic influence on this pathology.

Le syndrome de Takotsubo (STK) est une dysfonction ventriculaire gauche aiguë, le plus souvent réversible, sans rapport avec une maladie coronarienne. L'objectif de notre étude était d'explorer le lien entre l'incidence de cette maladie en été et divers paramètres météorologiques; température moyenne, nombre de canicules et nombre de jours au-dessus de 30 °C. 482 patients ayant présenté un syndrome coronarien aigu entre les étés 2012 et 2017 ont été analysés dans notre région (Valais, Suisse). Après application des critères d'éligibilité et d'exclusion, 15 avec un STK avéré ont été inclus dans l'étude. Les résultats montrent que l'incidence de STK était statistiquement plus élevée pendant les canicules (coefficient de corrélation: 0,77; p = 0,04), ce qui conforte l'hypothèse de l'influence des températures extrêmes sur l'incidence saisonnière de cette pathologie.

[Heart failure in year 2021: a review for the general practitioner]. / Insuffisance cardiaque en 2021 : un tour d'horizon pour le généraliste.

Heart failure has become a real public health problem impacting both the hospital system and the outpatient sector. In constant evolution, the therapeutic armamentarium has been enriched with new molecules, making treatment more effective. Optimal management of patients suffering from heart failure are multileveled and require a multidisciplinary team. The team consists of the in-charge general physician, a cardiologist, a trained nurse in therapeutic education, and optimally a dietician and/or physiotherapist. A limiting step towards the efficiency of patient management is the communication skills of the network.

À l'heure actuelle, l'insuffisance cardiaque est devenue un réel problème de santé publique qui impacte le système hospitalier comme le secteur ambulatoire. En constante évolution, le traitement médicamenteux s'est étoffé de nouvelles molécules, rendant la prise en charge plus efficace. Les défis pour une prise en charge optimale des patients souffrant d'insuffisance cardiaque sont multiples et requièrent une approche multidisciplinaire incluant bien évidemment le généraliste, le cardiologue mais aussi l'infirmière spécialisée en éducation thérapeutique, la diététicienne ou encore le physiothérapeute. L'augmentation du nombre d'intervenants nécessite une communication optimale et active entre les intervenants de l'hôpital et du cabinet.

[Heart and thromboembolic events: situation in 2021]. / Cœur et événements thromboemboliques : situation en 2021.

In daily practice, ischemia of embolic origin is frequent. The clinical spectrum can range from minor ischemia to stroke or myocardial infarction. This article summarizes the common etiologies of a cardioembolic event, such as atrial fibrillation or atrial flutter, presence of a patent foramen ovale or intracardiac masses (endocarditis, thrombi or tumors). This paper aims to serve as a short repository of information to guide every physician might need to initiate the diagnostic investigations and therapy according to recent recommendations.

Dans son quotidien, le praticien sera couramment confronté à une ischémie d'origine embolique. L'éventail clinique va d'une ischémie mineure à un AVC ou un infarctus du myocarde. Cet article résume les étiologies courantes d'un événement cardioembolique, notamment la fibrillation ou le flutter auriculaire, la présence d'un foramen ovale perméable ou de masses intracardiaques (végétations, thrombi, tumeurs). Il vise à guider le praticien dans sa prise en charge diagnostique et thérapeutique selon les recommandations cliniques récentes. Cette prise en charge est très souvent multidisciplinaire.

Stress Perfusion CMR in Patients With Known and Suspected CAD: Prognostic Value and Optimal Ischemic Threshold for Revascularization.

OBJECTIVES: This study sought to determine the ischemia threshold and additional prognostic factors that identify patients for safe deferral from revascularizations in a large cohort of all-comer patients with known or suspected coronary artery disease (CAD). BACKGROUND: Stress-perfusion cardiac magnetic resonance (CMR) is increasingly used in daily practice for ischemia detection. However, there is insufficient evidence about the ischemia burden that identifies patients who benefit from revascularization versus those with a good prognosis who receive drugs only. METHODS: All patients with known or suspected CAD referred to stress-perfusion CMR for myocardial ischemia assessment were prospectively enrolled. The CMR examination included standard functional adenosine stress first-pass perfusion (gadobutrol 0.1 mmol/kg Gadovist, Bayer AG, Zurich, Switzerland) and late gadolinium enhancement (LGE) acquisitions. Presence of ischemia and ischemia burden (number of ischemic segments on a 16-segment model), and of scar and scar burden (number and transmurality of scar segments in a 17-segment model) were assessed. The primary endpoint was a composite of cardiac death, nonfatal myocardial infarction (MI), and late coronary revascularization (>90 days post-CMR); the secondary endpoint was a composite of cardiac death and nonfatal MI. RESULTS: During a follow-up of 2.5 ± 1.0 years, 86 and 32 of 1,024 patients (1,103 screened patients) experienced the primary and secondary endpoints, respectively. On Kaplan-Meier curves for the primary and secondary endpoints, patients without ischemia had excellent outcomes that did not differ from patients with <1.5 ischemic segments. In multivariate Cox regression analyses of the entire population and of the subgroups, ischemia burden (threshold: ≥1.5 ischemic segments) was consistently the strongest predictor of the primary and secondary endpoints with hazard ratios (HRs) of 7.42 to 8.72 (p < 0.001), whereas age (≥67 years), left ventricular ejection fraction (≤40%), and scar burden (LGE score ≥0.03) contributed significantly, but to a lesser extent, in all models with HRs of 2.01 to 3.48, 1.75 to 1.96, and 1.66 to 1.76, respectively. CONCLUSIONS: In a large all-comer patient cohort with known and suspected CAD, an ischemia burden of ≥1.5 ischemic segments on stress-perfusion CMR was the strongest predictor of the primary and secondary endpoints. Patients with zero or 1 ischemic segment can be safely deferred from revascularizations.

[News about pericardial diseases in 2016]. / Maladies du péricarde : quoi de neuf en 2016 ?

The European Society of Cardiology published in 2015 the new Guidelines on the management of pericardial diseases. Based on experts' opinions and recent clinical studies of respectable size, the new guidelines thoroughly revisit the criteria for hospitalization and precisely define severe cases. Another highlight regards medication. From now, first-line medical therapy should include the association of colchicine to the traditional non steroidal anti-inflammatory drugs or aspirin. The bi-therapy is recommended as soon as the first episode of pericarditis, for duration of 3 months. The experts also recommend systematically performing a heart ultrasound for any form of pericardial disease and restricting physical activities especially if myocardial damage (perimyocarditis) is associated.

La Société européenne de cardiologie a publié de nouvelles recommandations en 2015 à propos des maladies du péricarde, apportant des précisions au niveau des thérapies avec notamment l'introduction en première ligne de la colchicine en association aux anti-inflammatoires non stéroïdiens (AINS) ou à l'aspirine, et ce dès le premier épisode de péricardite idiopathique. Les corticoïdes restent contre-indiqués en première ligne. Les experts préconisent en outre la réalisation systématique d'une échocardiographie cardiaque. Les critères d'hospitalisation sont précisés (fièvre, échec du traitement aux anti-inflammatoires non stéroïdiens) et il est rappelé la nécessité d'une restriction au niveau des activités sportives, en particulier lors d'une atteinte associée du myocarde.

Respiratory self-navigated postcontrast whole-heart coronary MR angiography: initial experience in patients.

PURPOSE: To assess the diagnostic performance of respiratory self-navigation for whole-heart coronary magnetic resonance (MR) angiography in a patient cohort referred for diagnostic cardiac MR imaging. MATERIALS AND METHODS: Written informed consent was obtained from all participants for this institutional review board-approved study. Self-navigated coronary MR angiography was performed after administration of a contrast agent in 78 patients (mean age, 48.5 years ± 20.7 [standard deviation]; 53 male patients) referred for cardiac MR imaging because of coronary artery disease (n = 40), cardiomyopathy (n = 14), congenital anomaly (n = 17), or "other" (n = 7). Examination duration was recorded, and the image quality for each coronary segment was assessed with consensus reading. Vessel sharpness, length, and diameter were measured. Quantitative values in proximal, middle, and distal segments were compared by using analysis of variance and t tests. A double-blinded comparison with the results of x-ray angiography was performed when such results were available. RESULTS: When patients with different indications for cardiac MR imaging were examined with self-navigated postcontrast coronary MR angiography, whole-heart data sets with 1.15-mm isotropic spatial resolution were acquired in an average of 7.38 minutes ± 1.85. The main and proximal coronary segments could be visualized in 92.3% of cases, while the middle and distal segments could be visualized in 84.0% and 55.8% of cases, respectively. Subjective scores and vessel sharpness were significantly higher in the proximal segments than in the middle and distal segments (P < .05). Anomalies of the coronary arteries could be confirmed or excluded in all cases. Per-vessel sensitivity and specificity for stenosis detection were 64.7% and 85.0%, respectively, in the 31 patients for whom reference standard x-ray coronary angiography results were available. CONCLUSION: The self-navigated coronary MR angiography sequence shows promise for coronary imaging. However, technical improvements are needed to improve image quality, especially in the more distal coronary segments.

[Practical approach of cardiac valvulopathies]. / Approche des valvutlopathies cardiaques par le praticien. Investigations diagnostiques et place du traitement médicamenteux.

In the light of the recommendations published in 2012 by the European Society of Cardiology, the present article provides a review of the assessment, diagnosis and drug therapy of frequent cardiac valvular disease in adults. Congenital valvular heart disease, as well as pathology of the pulmonary valve and tricuspid stenosis, which are less frequent, will not be discussed here.

[Quality of treatment after myocardial infarction: impact of hospital guidelines]. / Quatité du traitement après infarctus du myocarde: impact de recommandations hospitalières.

After myocardial infarction (MI), international societies of cardiology recommend an optimal treatment associating four classes of drugs, known as BASI combination (beta-blocker, antiplatelets, statin and inhibitor of the angiotensin converting enzyme). This study shows that the implementation of locally adapted guidelines in a regional hospital (CHCVs, Sion) significantly improve the treatment quality after MI, with a 10% increase of the BASI combination at discharge. Detailed results are discussed. Finally, we provide a table summarizing the optimal treatment strategy with drug examples including doses, which will be helpful to both general practitioners and specialists.

Traumatic mitral valve injury after blunt chest trauma: a case report and review of the literature.

Mitral valve injury after blunt chest trauma is a rare occurrence. We recently admitted a patient with severe traumatic mitral regurgitation who was successfully treated with surgery. Review of the literature aimed at taking an inventory of cases of traumatic nonpenetrating mitral insufficiency that were operated on, since the earliest report in 1964. Eighty-two cases were found and analyzed allowing for a better understanding of the epidemiology, etiology, natural history, pathology, and treatment of this rare condition. The most common lesions reach the papillary muscles (PM), followed by the chordae and then the mitral valve leaflets. Among the 82 cases reported that have been treated with surgery, 57% required a valve replacement. More than half of the patients had a PM injury with a complete or partial rupture. When the rupture is complete, and especially when it involves the anterior PM, the clinical picture is most always acute with clinically important hemodynamic repercussions, often necessitating emergency surgery, most of the time with mitral valve replacement. One must always suspect traumatic mitral injury after blunt chest trauma. The most common mitral lesions affect the PM. The clinical course can be indolent or devastating, and most often requires urgent or delayed surgical treatment, either with mitral valve repair or replacement.

[Public access defibrillation]. / Ombres et lumières de l'accès public a la défibrillation.

Placement of automated external defibrillators (AED) in public facilities and training of the lay persons in basic life support-defibrillation (BLS-D) was recommended by the American Heart Association for the treatment of out-of-hospital cardiac arrest (OHCA). Immediate use of AED result in increase of survival to hospital discharge. Many observation and much less randomized trials describe clinical efficacy of this approach. However, "negative" trials have also been published and some recent data suggest that public access defibrillation (PAD) will have a minimal impact on population survival. In this article various PAD strategies were briefly reviewed. In our opinion installation of AED in public places should be based on the long-term study of local OHCA demography and preceded by widespread BLS training of lay population.

Emergency percutaneous coronary interventions for acute myocardial infarction with ST-segment elevation in a regional hospital: a quality control study.

BACKGROUND: An invasive approach of acute myocardial infarction with ST-segment elevation (STEMI) with primary percutaneous coronary intervention (PCI) is currently considered as the most efficient revascularisation strategy and is performed around-the-clock in tertiary hospitals. The present study is aimed at investigating the short term outcome of primary PCI eligible patients after STEMI in a regional institution (CHCV, Sion) in comparison to a University Hospital (CHUV, Lausanne). METHODS: From January the 1st to December the 31st 2002, all consecutive STEMI patients of both centres who had an emergency coronary arteriography were included in the analysis. Clinical and angiographic data were retrospectively collected. The primary end point was the combined incidence of in-hospital death, reinfarction, and target vessel revascularisation (TVR) at 7 days. RESULTS: The analysis included 58 patients in the CHVC (60+/-13 years, 16% of whom were female) and 160 patients in the CHUV (63+/-12 years, 25% were female). Both populations were identical according to the severity of coronary artery disease and distribution of risk factors, except for smokers (55% in CHCV, 39% CHUV, p=0.04). Most of the patients were treated by PCI in both centres (80% CHCV versus 86% CHUV, p=NS). A low proportion in both groups underwent urgent surgical treatment (3.5% CHCV versus 5.5% CHUV, p=NS). At 7 days, adverse events free survival was not statistically different. CONCLUSION: These results were expected because the CHCV fulfils the international guidelines criteria for performance of emergency angioplasty. Our study demonstrates that around-the-clock primary PCI for acute STEMI can safely be done in a regional hospital (CHCV Sion) providing there is strict adherence to all aspects of international guidelines.

Nutritional factors in the control of blood pressure and hypertension.

Differing hypertension prevalence rates between certain population and age groups are partially due to differences in the intake of certain nutrients. Blood pressure is positively associated with higher sodium, alcohol, and protein intakes; it is inversely associated with potassium, calcium, and magnesium intakes. Salt may lead to an increase in blood pressure in the presence of salt sensitivity, but there is no inexpensive or easy strategy to identify salt-sensitive patients. Other risk factors for hypertension include obesity and lack of regular physical activity. The best strategy appears to be moderate salt restriction (6-7 g/day) in combination with an optimal compliance of the antihypertensive drug therapy, as well as adoption of the combination diet of the DASH study--a diet rich in fruits and vegetables, and thus rich in potassium. Current evidence does not support the increased intake of Ca2+ or Mg2+ for blood-pressure-lowering purposes only; however, calcium and magnesium may represent important components in the combination diet of the DASH study. It seems that it is the combination of these nutrients that is of crucial importance for the achievement of optimal blood-pressure reduction. Also recommended is a decrease in alcohol consumption and an increase in regular physical activity. Instead of a severe intervention with regard to 1 risk factor alone, positive changes in 5 habits combined--high salt intake, high sodium-to-potassium ratio, alcohol intake, calorie imbalance, and a sedentary life--may be the most realistic and effective strategy to counteract the present hypertension epidemic.