[Management of NSTEMI in a hospital without interventional cardiology and without use of GRACE score: Does the clinician appreciation match the GRACE score calculated retrospectively for the coronarography delay?] / Prise en charge des syndromes coronaires aigus sans sus décalage du ST dans un hôpital sans cardiologie interventionnelle : l'appréciation du clinicien rejoint-elle le score de GRACE dans le délai de réalisation de la coronarographie ?

PURPOSE: The management of non-ST segment elevation acute coronary syndromes (NSTEACS) remains an issue for mobidity, mortality, and an economic stake. The first aim of the study was to evaluate the additional value of the GRACE score for the compliance with the recommended times to coronary angiography in an hospital without interventional cardiology. We also analysed the in-hospital and 6-month mortality and the predictive factors of compliance for the coronarography delays. METHODS: Retrospective monocenter cross-sectional study including consecutive patients with chest pain suggestive of a NSTEACS during 1 year. Data of the delay to coronarography were collected and GRACE score was calculated a posteriori. RESULTS: The time to perform coronary angiography was non-compliant in 49% of cases (27 patients out of 55). The calculation of the GRACE score would have allowed correcting the delay for two patients of our cohort. Clinical appreciation, troponin elevation, ECG modifications were associated with the delay compliance. Age <75 years predisposed to recommended delays. Renal failure and history of coronaropathy were significantly associated with non compliant delays. A non-compliant delay was significantly associated with higher mortality. CONCLUSION: In our experience, the knowledge of the GRACE score had little impact on the timing of coronary angiography. However, as a predictor of mid and long term mortality, GRACE score remains SCA ST+ useful to intensify surveillance of high-risk patients.

Changes in characteristics of hospitalized heart failure patients in ten years: a single-center study.

BACKGROUND: Progress in therapy and the ageing patients hospitalized with heart failure may have impacted the characteristics of this patients. AIMS: We compared epidemiological data of patients admitted with heart failure during two periods separated by a 10 year interval. METHODS: Characteristics of 353 heart failure patients recruited between 2002 and 2004 with those of 304 heart failure patients recruited between 1992 and 1994 were compared retrospectively. RESULTS: There is now a majority of male patients (56.4%) not found ten years ago. The average age is unchanged (75.1+/-11 then 76.4+/-11 years) even though the proportion of patients aged over 70 years has increased (75% versus 70%). Hospital length of stay has fallen from 14+/-9 to 10+/-7 days. Hospital mortality (8%) are identical. The two main etiologies remain coronary and hypertensive heart disease at 29 and 24% respectively but these proportions are lower than ten years ago (42 and 28% respectively). The ejection fraction is more often preserved (56%) than before (44%). Increased prescription of inhibitors of the renin-angiotensin system and beta-blockers is confirmed. Post-hospital and total mortality has fallen by 50 and 30% from 30 to 16% and 35 to 24% respectively at the expense of a 25% increase in the frequency of hospital readmissions from 29 to 38%. CONCLUSION: Even if mortality has declined, heart failure remains a major public health burden with a significant number of hospital readmissions. Other approaches such as therapeutic education must therefore be developed.

[Torsades de pointes caused by cetirizine overdose]. / Torsades de pointes induites par surdosage en cétirizine: à propos d'un cas.

Several therapeutic substances can cause torsades de pointes, especially if they prolong the QT interval and/or if there is an associated hypokalaemia. Certain second generation H1 antihistamines have been incriminated in the occurrence of such ventricular arrhythmias, such as terfenadine and astezimole, which have been withdrawn. Cetirizine, widely used in the treatment of allergic reactions, is a second generation H1 antihistamine with as yet no precautions of use regarding rhythm disturbances. No documented case of arrhythmia attributable to this drug has been reported. We report the case of a dialysed patient with chronic renal failure who had symptomatic episodes of torsades de pointes in the context of hypokalaemia and cetirizine overdose. In the light of this observation it would appear that the prescription of cetirizine is contra-indicated under such conditions.

[Paradoxical pulmonary embolism. A rare complication of arteriovenous fistulization of an aorto-iliac aneurysm]. / Embolie pulmonaire paradoxale. Une complication exceptionnelle de la fistulisation artério-veineuse d'un anévrisme aorto-iliaque.

Aneurysms of the infra-renal abdominal aorta or iliac arteries result in ilio-caval compression in about 10% of cases which may cause venous thrombosis by stasis and pulmonary embolism. Fistulisation of these aneurysms into the inferior vena cava or an iliac vein is rare and paradoxical pulmonary embolism from arterial thrombus of the aneurysmal pouch is exceptionally rare. The authors report a new case in which the ilio-iliac arteriovenous fistula caused high output cardiac failure, ischaemia of the homolateral leg and pulmonary embolism. Doppler ultrasonography diagnosed the fistula and excluded a deep vein thrombosis. This case illustrated the essential value of clinical examination and of Doppler ultrasonography, especially of the abdomen, in the investigation of the causes of pulmonary embolism.

Coronary artery spasm in patients with normal or near normal coronary arteries. Long-term follow-up of 277 patients.

Most studies on the natural course of coronary artery spasm in patients with normal or nearly normal coronary arteries are based on medium-term follow-up in small populations. The present series includes 277 successive patients with a median follow-up of 89 months (range: 1 to 198 months). There were 206 men and 71 women whose mean age was 53.6 +/- 9.3 years. They were all assessed with coronary arteriography which revealed no stenoses greater than 50%. Spasm was confirmed during the coronary arteriography in 157 patients (56.7%), by a positive provocation test following the arteriography in 113 patients (40.8%), and by an electrocardiogram which showed Prinzmetal's variant angina in seven patients (2.5%). The majority of patients, 264 (95.3%) were treated with calcium channel blockers. At the end of this study: 35 patients (12.6%) were lost to follow-up; 20 patients (7.2% died) including 10 (3.6%) from cardiac causes; 18 patients (6.5%) experienced myocardial infarction in 11 of whom repeat coronary arteriography consistently demonstrated one or more significant stenoses (greater than 70%); 109 patients (39%) had persistent angina, in 52 of whom the severity (more than one episode per month) warranted repeat coronary arteriography which detected significant stenosis in 19 cases; 95 patients (34.3%) were asymptomatic. Multivariate statistical analyses showed that only predictors of major coronary events (death, myocardial infarction or angina requiring repeat coronary arteriography) were systemic hypertension or the finding of minor parietal irregularities on the initial coronary arteriogram. Conclusion. Despite treatment with calcium channel blockers, persistent or recurrent episodes of angina are frequently observed whereas complications such as myocardial infarction or death are rare.

[Pulmonary arteriovenous fistula. A rare cause of dyspnea and cyanosis in an adult]. / Communication artério-veineuse pulmonaire. Une cause rare de dyspnée et de cyanose chez l'adulte.

The authors report the case of a pulmonary arteriovenous fistula presenting with dyspnoea and cyanosis in a young adult. The malformation was situated on the proximal pulmonary vessels and was cured by surgical correction. The diagnostic value of the clinical signs and complementary investigations of this rare conditions, often detected during adulthood, is discussed. The functional tolerance of the condition is often variable. Oxygen desaturation of arterial blood indicates a right-to-left shunt. Pulmonary angiography enables visualisation of the lesions and guides surgical management. The prevalence of complications of this condition is not well known, but the potential severity is an argument for therapeutic intervention. Embolisation techniques are developing but there is a risk of a systemic embolism. Surgery is the reference for the treatment of proximal fistulae, its curative effect being immediate and definitive.

[Spasm of normal or irregular coronary arteries. Long-term outcome of 277 patients]. / Spasme sur artères coronaires normales ou irrégulières. Devenir à long terme de 277 patients.

The outcome of patients presenting with spasm of normal or subnormal coronary arteries is only known in small series of patients at medium-term. The authors reviewed the outcome of 277 successive patients over an average period of 86 +/- 43 months (12 to 174 months). There were 206 men and 71 women with a mean age of 54 +/- 9 years. Coronary angiography was performed in all cases and did not show any stenosis greater than 50%. Spasm was documented during coronary angiography in 157 cases (57%) by a positive Methergin test after coronary angiography in 113 cases (41%) and by an ECG recording of Prinzmetal angina in 7 cases (2.5%). Nearly all patients (264: 95%) were treated by calcium antagonists. At the end of follow-up, there were: 35 lost to follow-up (12.6%), 20 deaths (7.2%) of which 10 were cardiac (3.6%), 18 myocardial infarctions (6.5%): 11 had repeat coronary angiography which showed one or more new significant (> 70%) coronary lesions in all cases; 109 patients had persistence of chest pain (39%). The severity of symptoms in 52 cases (over one attack of chest pain per month) led to repeat coronary angiography which showed significant coronary disease in 19 cases; 95 patients (34%) were asymptomatic. A multivariate statistical analysis showed hypertension or subnormal appearances on the initial coronary angiography to be significant predictive factors for new coronary events (death, myocardial infarction or angina requiring repeat coronary angiography). The authors conclude that coronary spasm of angiographically normal or subnormal arteries is only well controlled at long-term in 39% of patients not lost to follow-up and is responsible for death or myocardial infarction in 11.6% of cases (nearly 1.5% per year).

[Detection of circulating endothelial cells: a new diagnostic test of angina at rest]. / Détection des cellules endothéliales circulantes: un nouveau test diagnostique de l'angor de repos.

The diagnosis of spontaneous angina depends on the recording of per-critical electrocardiographic changes. There is no simple biological test to make its retrospective diagnosis. The attack is usually triggered by instability of an atheromatous plaque which fissures and liberates endothelial cells in the blod stream. The detection of these cells cold therefore be a biological sign of this condition. The technique of detection of circulating endothelial cells by immuno-magnetic method was used in 3 groups of patients admitted to hospital within 24 hours: group I comprised 11 patients with acute myocardial infarction, group II comprised 23 patients who had suffered from spontaneous angina with ST segment depression during the attack and significant coronary arterial stenosis, group III comprised 6 patients with chest pain for which coronary angiography is normal and provocative test of spasm is negative. Circulating endothelial cells were detected in all patients of group I (100%), in 18 of the 23 patients of group II (78%) and only in one of group III (18%). These results confer on this biological test for spontaneous angina a specificity and predictive positive value of 83 and 95% and a sensitivity and negative predictive value of 78 and 50%. Therefore the detection of circulating endothelial cells could be used as a simple and reliable test for retrospective diagnosis of spontaneous angina. The mediocre sensitivity and negative predictive value may be explained by a mechanism other than fissuration of atheromatous plaque in some cases of spontaneous angina.

[Comparison of the antispastic effect of Bi-Tildiem 120 mg and Tildiem 60mg]. / Comparaison de l'effet anti-spastique du Bi-Tildiem 120 mg et du Tildiem 60 mg.

Diltiazem (Tildiem 60 mg) is a calcium channel blocker with demonstrated efficacy and safety in the treatment of stable angina pectoris and spastic angina. The sustained release formulation of diltiazem, allowing two daily doses (Bi-Tildiem 120 mg), is already marketed in France for the treatment of stable angina. It was therefore interesting to evaluate the efficacy and safety of this form, administered in two daily doses, in coronary spasm, versus the classical formulation, Tildiem 60 mg, given at the same daily dose, i.e. 240 mg, in three divided doses per day. We conducted a single-centre, randomized, double-blind, cross-over clinical study in twelve patients, eleven men and one woman, between the ages of 42 and 70 years, presenting with angina and normal coronary arteries and spasm documented by a positive methylergonovine (Methergin) test. They were divided into two groups of six patients receiving either Tildiem followed by Bi-Tildiem, or Bi-Tildiem followed by Tildiem. The characteristics of the two groups were comparable at the time of the selection visit. The methylergonovine test, used to assess the efficacy of the two treatments, was improved by Tildiem and Bi-Tildiem compared to the placebo test (p = 0.001 and 0.002), without any significant difference between Tildiem and Bi-Tildiem: an improvement was obtained in 11/12 and 10/12 patients, respectively. No deterioration of the test was observed with Tildiem or Bi-Tildiem compared to placebo. The coronary symptoms and blood diltiazem levels were similar with Tildiem and Bi-Tildiem. The results confirmed the safety of Bi-Tildiem. A single adverse effect was attributed to treatment: an episode of mild insomnia. No serious adverse effect were observed and none of the patients discontinued the study. The efficacy and safety of Tildiem and Bi-Tildiem are comparable in the treatment of spastic angina.

[Ambulatory venous thromboembolitic disease. Clinical, etiological and evolutive data]. / Maladie veineuse thrombo-embolique ambulatoire. Données cliniques, étiologiques et évolutives.

OBJECTIVES: Venous stasis in bedridden patients is recognized as one of the risk factors for venous thromboembolism but the phenomena is known to occur in ambulatory subjects and another cause must be involved. We investigated a series of consecutive ambulatory patients with venous thromboembolism in order to distinguish the particular clinical manifestations and possible aetiologies. METHODS: We compared a retrospective series of 120 consecutive patients with deep vein thromboembolism of the lower limbs and 127 patients with the same disease who had been bedridden at onset. In addition to the physical examination, the aetiological work-up included echography (n = 14), abdominal computed tomography (n = 38) and/or haemostasis studies (n = 61). Mean follow up was 23 +/- 13 months (range 1-45 months). RESULTS: Family history of deep venous thromboembolism was found in 17 patients and recurrence was observed in 50 patients. Phlebitis was on the right in 52 cases, on the left in 47 and bilateral in 17. Proximal locations were more frequent (74%) and pulmonary embolism occurred in one-half of the patients (n = 58). A cause was identified in 61 cases (50.8%): cancer (n = 24, 17 known, 7 previously unknown), dyscrasia (n = 17, protein S or C deficiency (5), increased plasminogen activator inhibitor I (8), circulating anticoagulants (3), hypofibrinogen (1), idiopathic varicose veins (n = 7), pregnancy (n = 5), oral contraceptives (n = 4) and other causes (n = 4). No cause was identified in 59 patients. Pulmonary embolism led to death in 4 cases. Seven patients were lost to follow-up and anticoagulation therapy was taken by 79 (72%) then interrupted in the others 3 to 6 months later. Eighteen patients died, 14 due to the underlying disease, 2 from new cancers and 12 after recurrent thromboembolism. CONCLUSION: Ambulatory venous embolism is as frequent as embolism in bedridden patients and the cause can be observed in 50% of the cases.

[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.

[Flecainide exercise induced left bundle branch with chest pain]. / Bloc de branche gauche douloureux d'effort induit par flécaïnide.

Ischaemia has been the suggested mechanism of simultaneous left bundle branch block and chest pain on effort with normal coronary angiography. This hypothesis is very controversial and was not the mechanism in the two new cases of this syndrome. The two patients in whom effort pain and left bundle branch block were observed had been treated for paroxysmal supraventricular tachycardia with flecaine. Withdrawal of the anti-arrhtymic resulted in the disappearance of this syndrome. In these cases, the ischaemic mechanism could be excluded without ambiguity. The flecaine was the only cause of rate-related LBBB by slowing conduction in the left bundle branch with no effects on coronary reserve. It would seem that LBBB alone was the cause of chest pain. The absence of coronary artery disease was confirmed in the first patient and the diagnosis was highly improbable in the second.

[Vasculitis complicating treatment with streptokinase: delayed allergic reaction]. / Vascularite compliquant un traitement par streptokinase: une réaction allergique tardive.

The authors report a case of vascular purpura occurring eleven days after the injection of streptokinase for a myocardial infarction. This adverse event falls within a context of hypersensitivity vasculitis (type III). In this particular case, imputation to the thrombolytic agent was established by the official method for the imputation of adverse or toxic effects of drugs. Routine renal function studies were normal. The outcome was satisfactory following rest only but the existence of a mixed cryoglobulinemia, responsible secondarily for cold-related distal ischemic symptomatology of the lower limbs led to the successful prescription of a short course of corticosteroids.

[Importance of venous angioplasty in the treatment of subclavian venous thrombosis due to thoraco-brachial outlet syndrome]. / Intérêt de l'angioplastie veineuse dans le traitement d'une thrombose de la veine sous-clavière due à un syndrome du défilé thoraco-brachial.

A patient with subclavian vein thrombosis was treated successfully by transluminal angioplasty after initial inefficacy of thrombolytic agents. Although employed previously in the treatment of intrinsic and extrinsic subclavian vein stenosis with variable results, this technique has not been used up to the present for the acute phase of thrombosis. Because of the presence of a thoraco-brachial outlet syndrome, the procedure was completed by a first rib resection. A control phlebography in forced abduction at two month follow up showed excellent permeability of the subclavian vein.