[Malignant fascicular ventricular tachycardia degenerating into ventricular fibrillation in a patient with early repolarization syndrome]. / Une tachycardie ventriculaire (TV) fasciculaire maligne dégénérant en fibrillation ventriculaire (FV) associée à un syndrome de repolarisation précoce.

A 45-year-old man was hospitalized for syncope due to fascicular ventricular tachycardia degenerating into ventricular fibrillation (VF). The electrocardiogram showed an early repolarization syndrome. The arrhythmia was repetitive and disappeared after oral hydroquinidine. An implantable cardioverter-defibrillator (ICD) was implanted; subsequently, the patient was arrhythmia free at 9 months follow-up.

Resistance to platelet antiaggregants: an important cause of very late thrombosis of drug eluting stents? Observations from five cases.

BACKGROUND: Very late thrombosis of drug eluting stents is a rare complication that might be triggered by resistance to platelet antiaggregants (PAAs). AIM: Following an initial case where clinical data strongly suggested resistance to PAAs, we carried out a prospective systematic analysis of platelet aggregation in four subsequent cases of late thrombosis. METHODS: Resistance to aspirin was investigated with the PFA-100 test employing a collagen-epinephrine cartridge (Platelet Function Analyzer; Dade Behring). Resistance to clopidogrel was determined by flow cytometry of intraplatelet vasodilator-stimulated phosphoprotein (VASP) phosphorylation. RESULTS: All four cases showed resistance to either aspirin or clopidogrel, and two cases showed dual resistance to both of these PAAs. CONCLUSION: Analysis of platelet function in a patient with late stent thrombosis is useful and may allow adaptation of subsequent patient management. The value of monitoring platelet function after implantation of a drug eluting stent should be evaluated in prospective studies.

[Study of a detection strategy for silent ischemia in diabetic patients: 18 month follow-up of the ARCADIA register]. / Etude d'une stratégie de détection de l'ischémie silencieuse chez les patients diabétiques: suivi à 18 mois du registre ARCADIA.

BACKGROUND: The prognostic impact of a myocardial ischemia-based therapeutic program in asymptomatic diabetic patients remains controversial. We prospectively assessed the benefit of a stratification algorithm based upon clinical and myocardial perfusion imaging (MPI) data on cardiovascular events in such patients in a non-randomized register. METHOD: 701 consecutive asymptomatic diabetic patients were classified to be at low or intermediate-to-high cardiac risk according to 13 simple boil-clinical parameters. Intermediate-to-high risk patients were scheduled for MPI and underwent either a conventional (Group 1, n=180) or an intensive multifactorial (Group 2, n=245) therapeutic program. Low risk patients (Group 3, n=276) underwent no specific management. RESULTS: At the end of the survey and as a consequence of intensive management, lipid lowering therapy, antiplatelet drugs, and beta-blockers were more often prescribed in Group 2 than in Group 1 (55, 31 and 17% versus 36, 23, and 8% respectively, p<0.01). Planned coronary angiography in case of severe ischemia on MPI and revascularization were more frequent in Group 2 (16.2 and 8.9%) than in Group 1 (8.0 and 2.8% - p<0.01). At 19-month follow-up (96.7% completed), major event rate in Group 2 was significantly lower than in Group 1 (3.9 versus 9.8%, p<0.01) and similar to that of Group 3 (2.2%, NS). CONCLUSION: Easy-to-perform risk stratification is able to select diabetic patients with good medium-term prognosis. In clinically selected higher risk patients, an intensive medical therapy combined with coronary angiography +/- revascularization in case of large ischemia on MPI is effective to improve prognosis.

Effects of a myocardial ischaemia-guided therapeutic program on survival and incidence of coronary events in asymptomatic patients with diabetes: the ARCADIA study.

AIM: To assess the prognostic impact of a therapeutic program based on bioclinical risk-stratification and myocardial-perfusion-imaging (MPI) data on survival and the occurrence of coronary events (CE=death+myocardial infarction) in asymptomatic patients with diabetes. METHOD: Five hundred twenty one consecutive asymptomatic diabetic outpatients were prospectively enrolled and clinically classified as being at either low or high cardiac risk. All high-risk patients (n=245, age 61+/-9 years) underwent MPI and an intensive multifactorial medical therapeutic program, including anti-ischaemic agents in cases of moderate ischemia; a coronary angiography was performed in all high-risk patients with severe ischaemia (n=38), followed by immediate revascularization if necessary (n=21). Low-risk patients (n=276, age 57+/-9 years) underwent medical management of their risk factors. RESULTS: At the 19-month (median) follow-up (range, 12-36 months), both high- and low-risk patients showed similarly low CE rates (2.3% and 1.5% per year, respectively; age- and gender-adjusted log-rank P=NS). None of the patients who underwent myocardial revascularization experienced any CEs, and none of the low-risk patients died during follow-up. The negative predictive value of first-line bioclinical stratification was 0.98 for the occurrence of CEs, and 0.95 when low-risk patients were combined with high-risk patients who had normal MPI findings. CONCLUSIONS: Bioclinical first-line stratification allows identification of diabetic patients who have a good medium-term cardiac prognosis. The CE rate is similar in selected high-risk asymptomatic patients with diabetes using an intensive MPI-guided program that combines medical therapy, coronary angiography in the 16% of cases with severe ischemia and, if appropriate, revascularization.

[Comparison of mortality according to the revascularisation strategies and the symptom-to-management delay in ST-segment elevation myocardial infarction]. / Comparaison de la mortalité en fonction de la stratégie de revascularisation et du délai douleur-prise en charge des syndromes coronaires aigus avec sus-décalage du segment ST.

The aim of this study was to compare the mortality associated to primary angioplasty and thrombolysis in patients managed for an elevated ST-segment acute coronary syndrome in less than or more than 3 hours after the onset of symptoms. We analyzed the in-hospital mortality of 846 patients (including 276 [33%] treated by primary angioplasty, 511 [60%] by thrombolysis, and 59 [7%] without revascularisation) included from October 2002 to December 2003 in a registry of patients with an elevated ST-segment acute coronary syndrome managed in less than 12 hours in Northern Alps districts. The overall in-hospital mortality was at 6.0% (51/846). For the 631 managed in <3 hours, the mortality rates were respectively at 5.0%, 4.6% and 11.1% respectively in case of primary angioplasty, thrombolysis and without revascularisation (p=0.21). For the 215 patients with pain lasting more than 3 hours, the mortality rates were at 2.7%, 10.3% and 21.7% in case of primary angioplasty, thrombolysis and no revascularisation, respectively (p=0.01). In the multivariable analysis, the OR of death in case of thrombolysis compared to primary angioplasty was at 1.65 (95% IC: 0.73 - 3.75) for patients with pain " 3 hours, and 4.98 (95% IC: 1.32-18.37) for those with pain > 3 hours. These results are in line with randomized trials conclusions and confirm the international guidelines suggesting primary angioplasty for patients with a chest pain >3 hours and either angioplasty or thrombolysis in case of chest pain < 3 hours.

[Coronary risk related to sport]. / Risque coronaire lié au sport.

Regular physical activity is beneficial because it is associated with a 40% reduction in the risk of death or myocardial infarction. However, sport momentarily increases the risk of adverse cardiovascular events during the sporting activity. This increased risk is higher in the less accomplished sportsmen and in those with cardiovascular risk factors. Regular weekly exercise, even of mild to moderate intensity, has a protective effect. An adverse coronary event on exercise is observed in 1200 to 1500 patients per year in France. It results from underlying coronary artery disease which is often occult. In the under 35 year age group, although atherosclerotic plaque is already present, the possibility of a congenital anomalous coronary arterial anatomy should be considered. This can sometimes be detected by transoesophageal echocardiography. After 35 years of age, coronary arteriosclerosis is almost the only pathology observed. The probability of a coronary event is higher in under trained "veteran" with known classical cardiovascular risk factors, often occurring by "error" in the practice of an activity too intense for the level of physical fitness. It should be remembered that 50% of these complications occur in people who have experienced symptoms on exercise in the days or weeks before the event. This article also discusses which risk factors aggravate the risk in known coronary patients and what advice should be given to coronary patients who want to benefit from the effects of regular physical exercise.

[Pacemaker and intra cardiac defibrillator lead extraction techniques]. / Les techniques de remplacement de matériel de stimulation cardiaque et défibrillation implantable.

Percutaneous Pace-maker and ICD lead extraction techniques has been developped: by superior approach using locking stylet and more and more efficient outher sheats (laser assisted); and also by femoral approach using double lasso catheters (Needle's eye snare). Indication range has increased and is not only reserved for lead infection. Because of scar tissue holding the lead and also the impact of the distal tip, those techniques are not simples. Extraction recommandations do advise those procedures to be performed by expert physicians, in cardiac surgery centers, where complications can be managed and reduced. The use of laser assisted outher sheats will make lead extraction easier and will reduce complication rate. Alternative procedure in case of failure with superior approach remain femoral approach. All those techniques give a success rate of about 98 % for percutaneous lead extraction in an expert center.

[Value of memory functions in implantable prostheses]. / Apport des mémoires embarquées dans les prothèses implantables.

The development of memory functions with memorised electrogrammes is one of the most important technical advances in cardiac pacemakers and defibrillators. These memory functions are very useful in the management of patients with implanted prostheses. In the case of defibrillators, the memory allows evaluation and validation of appropriate treatments (shock or asymptomatic antitachycardia stimulation) or inappropriate function. The memory can also help assess the efficacy of complementary antiarrhythmic therapy or radiofrequency ablation. The incorporation of memory functions in pacemakers is more recent but no less useful. The latest generation of pacemakers have not only a therapeutic but also a diagnostic role with respect to atrial and ventricular arrhythmias. They can lead to the prescription of an antiarrhythmic or anticoagulant drug in cases of sustained atrial fibrillation confirmed by the memorised electrogrammes. The memory function is also a great aid in reprogramming stimulators in cases of overdetection (V-A cross talk). They may also be activated by the patient in cases of sporadic paroxysmal symptoms. The latest development is that of a purely diagnostic prosthesis: the implantable Holter, whose main indication is in the investigation of unexplained syncope.

[Strategy of investigation of coronary artery disease in diabetes: from screening to suspicion of acute coronary syndromes]. / Stratégie d'exploration coronaire chez le diabétique: du dépistage à la suspicion de syndrome coronaire aigu.

Coronary artery disease is a common and serious condition in diabetes and the prognosis of the diabetic without a history of cardiovascular disease is either the same or nearly as serious as that of a non-diabetic patient with a history of coronary disease. This is particularly true in women. The prognosis is even worse in the presence of silent myocardial ischaemia. Conversely, anti-ischaemic and anti-thrombotic therapy and myocardial revascularisation of most severely affected patients are effective. This justifies the recent recommendations (as those of the working group of the French Society of Cardiology and the ALFEDIAM) for the diagnosis of coronary artery disease in diabetes, even in asymptomatic patients. This is a two stage process: --First, the identification of patients who should be screened for ischaemia, diabetics with a priori an intermediate or high risk of the presence of CAD, with respect to the presence of markers easily identified on initial examination, like the presence of clinical macroangiopathy (femoral, carotid), of renal disease or ECG changes or the presence of several classical risk factors; --The second stage is the demonstration of myocardial ischaemia in patients identified to be at risk. This article reviews the advantages and limits of the tests available: ECG stress test, myocardial perfusion imaging on effort or under dipyridamole, stress echocardiography. Coronary angiography in asymptomatic patients is only recommended in the presence of significant ischaemia or with a poor prognosis (affecting over 20% of the myocardium or several myocardial territories). This should precede a myocardial revascularisation procedure. The prescription of coronary angiography may be more direct in some symptomatic patients.

[Role of atrial stimulation in the treatment of paroxysmal atrial fibrillation]. / Place de la stimulation auriculaire dans le traitement de la fibrillation auriculaire paroxystique.

Preventive treatments for atrial fibrillation by stimulation have been developed for several years now, mainly due to the relative failure of anti-arrhythmic treatments. They are based on the hypothetical effects of stimulation by controlling cardiac frequency, abolishing bradycardia-dependent extrasystoles, by the inhibition of atrial automatic foci with "overdrive", and by the modification of intra- or inter-atrial conduction delays as well as by remodelling the arrhythmogenic substrate. It is clear that an undeniable effect exists for the prevention of atrial fibrillation, even for the risk of cerebral vascular accident, by physiological stimulation (DDD/DDDR) compared to pure ventricular stimulation (VVI/VVIR) in a heterogenous global population of stimulated patients. For the moment, there is not sufficient proof of a positive effect for the emerging sites of cardiac stimulation, either atrial mono-site or double site in the populations at high risk of atrial fibrillation, with or without associated bradycardia. Some new prevention algorithms by "overdrive" are under development but for the moment only a few preliminary studies seem to show a slight benefit. It is clear that at present stimulation should be reserved only for cases of atrial fibrillation associated with a classic indication for implantation. In these patients it is recommended to position the probes in an optimal manner in order to counteract conduction disorders, choosing an adapted double chamber stimulator with prevention algorithms. That said, the patient should be clearly warned that the long term success rate is no more than 50%.

Local delivery of nadroparin for the prevention of neointimal hyperplasia following stent implantation: results of the IMPRESS trial. A multicentre, randomized, clinical, angiographic and intravascular ultrasound study.

BACKGROUND: We hypothesized that intramural delivery of nadroparin, a low molecular weight heparin, would prevent in-stent restenosis by inhibiting neointimal hyperplasia in an angioplasty model free of arterial remodelling. METHODS AND RESULTS: In a prospective randomized multicentre trial, 250 patients submitted to balloon angioplasty followed by stent implantation were randomized into control group (no local drug delivery) or intramural delivery of nadroparin (2 ml of 2500 anti-Xa-units/ml with a microporous catheter). An ancillary intravascular ultrasound substudy was performed to supplement angiographic data with specific measurements of in-stent neointimal hyperplasia. The primary end-point was the late loss in minimal luminal diameter on the 6 month follow-up angiogram. Secondary end-points included feasibility and safety of local nadroparin delivery, and major adverse cardiac events at 8 weeks and 6 months follow-up. Local delivery of nadroparin was successful in 124 patients (99.2% success rate) and was not associated with an increase in stent thrombosis, coronary artery dissection, side branch occlusion, distal embolization or abrupt arterial closure. At angiographic follow-up, the late loss in lumen diameter was 0.84 +/- 0.62 mm in the control group compared to 0.88 +/- 0.63 mm in the nadroparin group (P=0.56). Angiographic restenosis rate (defined as a >50% diameter stenosis) did not differ in the control group (20%) compared to the nadroparin group (24%). The average area of neointimal tissue within the stent was 2.86 +/- 0.64 mm(2) vs 2.90 +/- 0.53 mm(2) (P=0.57), control vs nadroparin groups. There was no difference in major adverse cardiac events at any time (88.8% vs 89.6% event free survival at 6 months, control vs nadroparin). CONCLUSION: Intramural delivery of nadroparin with a microporous catheter after stent deployment was feasible and safe but had no effect in reducing restenosis or the occurrence of major adverse clinical events over 6 months.

Biodistribution, dosimetry, and safety of myocardial perfusion imaging agent 99mTcN-NOET in healthy volunteers.

UNLABELLED: 99mTcN-NOET (bis[N-ethoxy,N-ethyl]dithiocarbamato nitrido technetium (V)) has been proposed for myocardial perfusion imaging. Biodistribution, safety, and dosimetry were studied in 10 healthy volunteers (5 at rest and 5 during exercise). METHODS: Biodistribution was studied by acquiring dynamic images up to 60 min after injection and whole-body images up to 24 h after injection. The MIRDOSE3 analysis program was used for radiation dosimetry calculations. RESULTS: Safety parameters measured to 48 h after injection revealed no clinically significant changes. Cardiac uptake of 99mTcN-NOET was high (2.9%-3%), with biologic half-life of 210-257 min on average. Lung uptake of 99mTcN-NOET was higher (10%-20%) but, on average, biologic half-life was shorter (1-77 min). Clearance from the blood was rapid (5% by 5 min). Radiation dosimetry calculations indicated an effective absorbed dose of 5.11 x 10(-3) mSv/MBq at rest and 5.38 x 10(-3) mSv/MBq after exercise. CONCLUSION: 99mTcN-NOET exhibits high cardiac uptake and an estimated effective absorbed dose comparable with that of the other 99mTc-labeled compounds used in myocardial perfusion imaging.

[Which coronary tests to use in asymptomatic diabetics?]. / Quelles explorations à visée coronaire chez le diabétique asymptomatique?

Coronary artery disease is a common, serious and insidious complication of diabetes. Myocardial ischaemia is often silent. All diabetics do not have the same coronary risk and, therefore, it is important to determine which investigations to perform and which patients. This strategy is justified because it allows identification of these cases which require a medical or an invasive (angioplasty, surgical revascularisation) approach, as these interventions may improve the prognosis. The first stage is clinical (investigation of cardiovascular risk factors). When more than two risk factors are found, further investigations are justified. Exercise stress testing provide reassuring diagnostic and prognostic data when maximal and negative. When sub-maximal, impossible or significantly ischaemic, a second investigation is useful. Holter ECG recording with analysis of ST variation lacks sensitivity and, above all, specificity. The diagnostic value of perfusion myocardial scintigraphy in the diabetic is not as good as that observed in the general population, but its prognostic value remains good. Ischaemia involving over 20% of the myocardium justifies therapeutic investigation. Stress echocardiography has been validated in the diagnosis and prognosis of coronary artery disease and its sensitivity and specificity are probably the same as those of scintigraphy. The authors conclude that the asymptomatic diabetic requires clinical and staged paraclinical investigation to assess prognosis and, depending on the results, the adoption of a beneficial therapeutic strategy.

Long-term additive prognostic value of thallium-201 myocardial perfusion imaging over clinical and exercise stress test in low to intermediate risk patients : study in 1137 patients with 6-year follow-up.

BACKGROUND: The exercise treadmill test (ETT) and Tl201 single proton emission computed tomography (SPECT) are of short- to medium-term prognostic value in coronary heart disease. We assessed the long-term prognostic value of these tests in a large population of patients with low- to intermediate risk of cardiac events. METHODS AND RESULTS: One thousand one hundred thirty-seven patients (857 men, age 55+/-9 years) referred for typical (62.1%) or atypical (22.4%) chest pain, or suspected silent ischemia (15.5%), were followed up for 72+/-18 months. Overall mortality was higher after strongly positive (ST depression >2 mm, or >1 mm for a workload /=3 abnormal segments on SPECT, respectively (P<0.002). An abnormal SPECT was predictive of MI (P<0.001), whereas ETT was not. In multivariate analysis, SPECT was of incremental prognostic value over clinical and ETT data for predicting overall mortality and major cardiac events. CONCLUSIONS: The incremental predictive value of SPECT is maintained over 6 years and is particularly relevant after positive, strongly positive, and nondiagnostic ETT.

A randomized evaluation of early revascularization to treat shock complicating acute myocardial infarction. The (Swiss) Multicenter Trial of Angioplasty for Shock-(S)MASH.

AIM: To test whether emergency revascularization improves survival in patients with acute myocardial infarction and shock. METHODS AND RESULTS: Patients with acute myocardial infarction and early shock were randomized either to undergo emergency angiography, followed immediately by revascularization when indicated, or to receive initial medical management. In five of the nine participating centres, patients with shock but not randomized were entered in a registry. Only 55 patients could be randomized. Of the 32 patients in the invasive group, 30 (94%) underwent early angiography, 27 (84%) PTCA, and one (4%) CABG. Twenty-two (69%) died within 30 days in the invasive group vs 18/23 (78%) in the medically managed group (ns, RR=0.88, 95% confidence interval 0.6-1.2). Among the registry patients, 24/51 were excluded from randomization solely because of patient or physician preference for the invasive approach: 23 (96%) of them underwent emergency angiography, 21 (88%) PTCA, and 12 (50%) died within 30 days. Among the remaining registry patients (n=27) only nine (33%) underwent early angiography, nine (33%) PTCA and 20 (74%) died. CONCLUSION: We failed to demonstrate that emergency PTCA significantly improves survival in patients with acute myocardial infarction and early cardiogenic shock. Because the study was stopped prematurely, due to an insufficient patient inclusion rate, a clinically meaningful benefit of early reperfusion may have been missed.