[Coronary angioplasty during the acute phase of myocardial infarction in the aged subject]. / Angioplastie coronaire à la phase aiguë de l'infarctus du myocarde chez le sujet âgé.

Myocardial infarction is a common and serious condition in patients over 70 years of age. The aim of this study was to assess the feasibility and efficacy of angioplasty without thrombolysis for revascularising an occluded artery in this age group. Between March 1986 and December 1989, 32 patients over 70 years of age (average 76 +/- 3 years) underwent angioplasty without thrombolysis in the acute phase of myocardial infarction. During the same period, 83 patients under 70 years of age were treated in the same manner. In the elderly subjects, the initial lesion was a total occlusion in 26 out of 32 cases (81%) and 99% stenosis in the other 6 cases (19%), and was successfully revascularised in 28 of the 32 patients (87.5%). Three episodes of ventricular fibrillation occurred during the procedure, one of which was lethal. A recurrence of pain during the hospital period was observed in 3 patients, 1 of whom died and the other 2 underwent repeat angioplasty. The hospital mortality was 5 patients (16%), all of whom were over 75 years of age. The comparison with patients under 70 years of age showed a comparable primary success rate, 87.5% (28/32) versus 92% (76/83) (p = 0.5), but a higher mortality, 16% (5/32) versus 4% (4/83) (p < 0.05) and a tendency to worse left ventricular function (ejection fraction 51% versus 62%) and to more extensive coronary artery disease; on the other hand, the post-hospital outcome was the same in both groups; Globally, emergency coronary angioplasty is a valuable alternative to thrombolysis for the treatment of myocardial infarction in patients over 70 years of age.

Influence of the rt-PA dose (1 mg/kg versus 1.5 mg/kg) and duration of administration on the patency of infarct-related coronary arteries in 81 patients.

This open study compared the efficacy and side effects of two dose regimens of intravenous rt-PA initiated before the fifth hour after the onset of myocardial infarction. The first 40 patients (group A) received 1 mg/kg of rt-PA infused over 90 minutes, including a 10-mg initial bolus. The following 41 patients (group B) received 1.5 mg/kg (20-mg initial bolus, 60% over 60 minutes and 40% over 120 minutes). Noninvasive clinical, electrocardiographic, and biochemical parameters of reperfusion were recorded systematically, along with serial measurements of fibrinogen and hemoglobin levels. Coronary arteriography and left ventriculography were performed at the 48th hour or earlier, on an emergency basis, in the absence of signs of reperfusion, or if there were clinical and ECG signs of rethrombosis. Patency of the infarct-related artery (TIMI grades 2 and 3) was achieved in 55% of the group A patients vs. 83% of the group B patients (p less than .01). Twelve emergency coronary arteriographies were performed in each group. No significant difference was observed in the ejection fraction (48% in group A vs. 52% in group B). The peak CPK level was similar in both groups, but the peak occurred earlier in group B (p less than .001). There was no statistically significant difference between the two dose regimens in terms of reduction in fibrinogen or plasminogen levels. Two deaths occurred in group A vs. one death in group B. No cerebrovascular accidents occurred in either group.(ABSTRACT TRUNCATED AT 250 WORDS)

[How to evaluate the cost/effectiveness ratio of different therapies of coronary disease]. / Comment évaluer le rapport coût/efficacité des différentes thérapeutiques de la maladie coronarienne.

The results of epidemiologic studies on the efficacy of different strategies of prevention or improvement of the prognosis of coronary artery disease are generally expressed in terms of percentage reduction of risk; for example, the treatment of hypercholesterolaemia reduces the risk of coronary death by 21%. In order to improve the assessment of the efficacy of these approaches the authors propose to take into account the number of subjects which needs to be treated each year to prevent one cardiovascular event more than the control group (for example, in hypercholesterolaemia, 1,736 patients). This number depends on the reduction of risk and also on the incidence of complications in the control group. Using this method, the authors classified different therapeutic strategies in order of their efficacy: thrombolytic therapy in the acute phase of myocardial infarction, then aortocoronary bypass grafting of left main coronary or triple vessel disease, secondary prevention with stopping smoking, and betablocker therapy. Finally, primary prevention with anti-smoking campaigns, treatment of hypertension and hypercholesterolemia. Based on this figure and knowing the annual cost of patient treatment, it is possible to calculate a cost-effectiveness ratio for each of these therapeutic interventions.

[Ventricular arrhythmias disclosing myocardial abscess in infectious mitro-aortic endocarditis]. / Troubles du rythme ventriculaires révélateurs d'un abcès myocardique au cours d'une endocardite infectieuse mitro-aortique.

The authors report the case of a myocardial abscess in an infectious endocarditis with a double localization, mitral and aortic. The way it is revealed, by severe and recurring ventricular arrhythmias, differs from the conduction disorders usually described. The diagnosis is suspected by non-invasive examinations, echocardiography and nuclear magnetic resonance. It is backed up by angiographic exploration. The intervention confirms the data obtained by cardiac imaging, and enables the ablation of the abscess which is cleaned out, and the cure of the valvular lesions. Taking into account the gravity of this complication, a close clinical, electrocardiographic and echocardiographic surveillance of all infectious endocarditis is necessary.

[A rare cause of acute circulatory failure with pulmonary edema: catecholergic cardiomyopathy of pheochromocytoma]. / Une cause rare de défaillance circulatoire aiguë avec oedème pulmonaire: la cardiomyopathie catécholergique du phéochromocytome.

We report the case of a 37 years old woman with pheochromocytoma of the adrenal gland, with acute circulatory failure and pulmonary oedema. Its originality lies, besides the rare circumstances of diagnosis, in the echographic aspect of the left ventricle with an apical myocardial infarction with both severe apical hypokinesia and compensating basal hyperkinesia. In the literature the most frequent aspect of catecholamine cardiomyopathy is a large uniform dilatation of the left ventricle with often wall hypertrophy. After surgical ablation of the left adrenal gland tumor, we observe quickly a complete normalisation of the picture and especially the echocardiogram. The cardiomyopathy and the pulmonary oedema can result from the specific action of the excess catecholamines on the myocardial cells and the pulmonary capillaries.

[Two-dimensional echocardiography during the acute phase of myocardial infarction. Diagnostic and prognostic value]. / Echocardiographie bidimensionnelle à la phase aiguë de l'infarctus du myocarde. Valeur diagnostique et pronostique.

A bidimensional cardiac sonogram was performed in 152 consecutive patients with in 24 hours after hospitalization in the intensive care unit for acute myocardial infarction, in order to evaluate the contribution of this technique to the diagnosis, determination of early complication and the prognosis. For this study, the left ventricle was divided in 10.segments. For each segment, systolic mobility as well as thickness were evaluated. It was possible to obtain a proper recording in 134 patients. Abnormal left ventricular kinetics (at least 1 segment) is present in all anterior transmural infarctions with, in 90 p. cent of the cases, a concordance between electrical and sonographic localization and in 89 p. cent of inferior between electrical and sonographic localization and in 89 p. cent of inferior only present in 65 p. cent. Abnormal kinetics is only present in 65 p. cent of non transmural infarctions. In 15 patients with clinical infarction without any electrical sign, the cardiac sonogram permitted to make the diagnosis and establish the localization of the infarction. In 46 p. cent of the cases, a left ventricular asynergy was observed at a distance of the necrosed area. In these patients, the mortality and cardiogenic shock rates during hospitalization were higher than for patients who did not present these abnormal findings (p less than 0.01). In conclusion, bidimensional cardiac sonography is a very specific diagnostic tool, permitting an early prognosis and able to detect early complication, especially of pericardial and mechanical nature.