[Implementation of reperfusion therapy in ST segment elevation myocardial infarction (STEMI). A policy statement from the Belgian Society of Cardiology and its working group of acute cardiology and interventional cardiology]. / Mise en pratique du traitement de reperfusion dans les infarctus du myocarde avec élévation du segment ST (STEMI). Recommandations actualisées de la Société Belge de Cardiologie et de ses groupes de travail: le Groupe Interdisciplinaire de Cardiologie Aiguë (BIWAC) et le Groupe de Cardiologie Interventionnelle (BWGIC).

Myocardial infarction remains a major healthcare problem. Reperfusion therapy has been shown to influence favourably short- and long-term patient survival. The authors reviewed the data of early recognition of STEMI (ST Elevation Myocardial Infarction), the reperfusion modalities including a flowchart management, as proposed by the Belgian working groups (BIWAC and BWGIC), and the lessons learned from European and American registries. Primary PCI often remains the treatment of choice. A national policy is still required to implement the guidelines and improve clinical practice for our STEMI patients.

[Implementation of reperfusion therapy in ST segment elevation myocardial infarction (STEMI). A policy statement from the Belgian Society of Cardiology and its working group of acute cardiology and interventional cardiology]. / Mise en pratique du traitement de reperfusion dans les infarctus du myocarde avec élévation du segment ST.

Myocardial infarction remains a major healthcare problem. Reperfusion therapy has been shown to influence favourably short- and long-term patient survival. The authors reviewed the data of early recognition of STEMI (ST Elevation Myocardial Infarction), the reperfusion modalities including a flowchart management, as proposed by the Belgian working groups (BIWAC and BWGIC), and the lessons learned from European and American registries. Primary PCI often remains the treatment of choice. A national policy is still required to implement the guidelines and improve clinical practice for our STEMI patients.

Co-administration of ezetimibe and simvastatin in acute myocardial infarction.

BACKGROUND: Recent trials in acute myocardial infarction indicate that intensive and early statin therapy that lowers low-density lipoprotein cholesterol (LDL-C) to < or = 70 mg dL(-1) is beneficial. The combination of statins with ezetimibe, a newly developed cholesterol-absorption inhibitor, can lead to a further reduction in LDL-C of up to 26%. In this study, we examined the rapidity and intensity of the lipid-lowering effect of ezetimibe co-administered with simvastatin immediately after myocardial infarction. MATERIALS AND METHODS: Sixty patients admitted for acute myocardial infarction were randomized to receive either simvastatin 40 mg (SIMVA), a combination of simvastatin 40 mg and ezetimibe 10 mg (EZE/SIMVA), or no lipid-lowering drugs (NLLD) and had their lipid levels assessed 2, 4 and 7 days later. RESULTS: At baseline, cardiovascular risk factors were similar in all three groups [mean (SD) LDL-C of 141 (36) mg dL(-1)]. At days 2 , 4 and 7 there was no significant change in mean LDL-C levels in the NLLD group (-10%, -6%, and -9%, all P > 0.09), while there were significant reductions with SIMVA (-15%, -27%, and -25%, respectively, all P < 0.001 vs. day 0) and even greater reductions with co-administration of EZE/SIMVA (-27%, -41%, and -51%, respectively, all P < 0.001 vs. day 0). The percentages of patients achieving LDL-C below 70 mg dL(-1) at days 4 and 7 were substantially greater with EZE/SIMVA (45% and 55%, respectively) than with SIMVA (5% and 10%, respectively), while no NLLD patient reached this goal. Triglyceride levels showed a progressive increase in the NLLD group (+45% at day 7, P < 0.05 vs. day 0), no change in the SIMVA group, but a decrease in the EZE/SIMVA group (-17% at day 7, P < 0.05 vs. day 0). No significant difference in HDL-C levels, tolerability, or clinical events was observed between the three groups. CONCLUSIONS: The co-administration of ezetimibe 10 mg with simvastatin 40 mg, by inhibiting cholesterol absorption and production, allowed more patients with acute myocardial infarction to reach LDL-C < or = 70 mg dL(-1) as early as the fourth day of treatment. The effects of such rapid and intense reduction in LDL-C on cardiovascular morbidity and mortality need to be evaluated in future clinical endpoint studies.

[Doppler ultrasound and aortic regurgitation. Evaluation of the sensitivity and specificity of Doppler findings]. / Echo-Doppler artériel et insuffisance valvulaire aortique. Etude de la sensibilité et de la spécificité des signes.

PURPOSE: The purpose of this study was to determine the sensitivity and specificity of arterial Doppler findings of aortic regurgitation to assess if the amplitude of changes of Doppler tracings can accurately quantify the degree of regurgitation. PATIENTS AND METHODS: We analysed and compared the arterial Doppler tracings and echocardiograms of 250 patients. RESULTS: Even if the obvious pitfall of vascular stenoses is avoided, the global sensitivity of arterial Doppler findings for aortic regurgitation remains weak (30%). However, our study demonstrates that it can reach 100% if only significant AR (> or =2/4) is taken into account. Since the clear false-positive cases have been carefully excluded from the very start, the specificity of the classical criteria already proves excellent (above 95%). It will reach perfection if additional simple criteria gathered from the data mentioned in this study are considered. Quantifying precisely the degree of aortic regurgitation on the basis of arterial Doppler tracings is impossible. Nevertheless, we show that it is easy to identify significant AR (> or =2/4) that should be further assessed with echocardiography. CONCLUSION: Arterial Doppler sonography is unable to detect all cases of aortic regurgitation but those that are overlooked are not significant (1/4). If AR signs happen to be detected by arterial Doppler, the amplitude of the leak cannot be accurately determined based on tracing analysis. Yet, simple criteria will indicate whether it is important enough (> or =2/4) to require complementary echocardiogram, with well documented accuracy for morphological and hemodynamic evaluation.

[Recommendations for management of acute chest pain. Report of the Belgium Interdisciplinary Working Group on Acute Cardiology]. / Recommandations pour la prise en charge de douleurs thoraciques aiguës. Rapport du Groupe Interdisciplinaire Belge de Cardiologie Aiguë (BIWAC: Belgium Interdisciplinary Working group on Acute Cardiology).

The Belgium Interdisciplinary Working group on Acute Cardiology, including cardiologists, intensivists and urgentists was formed to provide consensus regarding the management of acute chest pain in the prehospital and the early hospital phase. General recommendations and critical pathways are proposed to improve the treatment of the patients with acute coronary syndromes.

[Recommendations for the management of acute chest pain. Report of the Belgian Interdisciplinary Group on Acute Cardiology]. / Recommandations pour la prise en charge de douleurs thoraciques aiguës. Rapport du Groupe Interdisciplinaire Belge de Cardiologie Aiguë.

The Belgium Interdisciplinary Working Group on Acute Cardiology (BIWAC), including cardiologists, intensivists and urgentists was formed to give consensus regarding the management of acute chest pain in the prehospital and the early hospital phases. General recommendations and critical pathways are proposed to improve the treatment of the patients with acute coronary syndromes.

Fatal overdose with trazodone: case report and literature review.

A fatal case of suicide with trazodone alone in a 40-year-old patient is reported. Life-threatening arrhythmias, such as torsades de pointes and complete AV block, are recorded. Blood collected at admission contained a trazodone toxic concentration of 25.4 micrograms/mL. The patient developed multiple organ failure and died less than 24 hours after his admission to the emergency department. The authors discuss the effects of overdose of trazodone, a well-known safe antidepressant drug.

ICD malfunction caused by excessive defibrillation charge time.

A 71-year-old man with a history of myocardial infarction and syncopal ventricular tachycardia received an ICD. Progressively, increased defibrillation charge times of the ICD were observed. During a fast ventricular tachycardia, the patient collapsed. The underlying malfunction could be documented by ICD telemetric interrogation. An excessive charge time was recorded causing subsequent delayed therapy. The ICD was considered potentially ineffective and required a generator exchange. This case report underlines the possible factors affecting the ICD charge times. Excessive charge time must be considered as a rare, or underestimated, cause of ICD malfunction, requiring generator replacement.

Symptomatic pericarditis after influenza vaccination: report of two cases.

The authors report two cases of benign acute pericarditis after the patients received vaccinations against influenza virus. The diagnoses were confirmed by serologic changes and by the findings of 12-lead electrocardiogram and echocardiography. Symptoms and clinical status improved on aspirin therapy. The authors underline the possible mechanisms of this rare complication of influenza vaccination.

Paroxysmal atrioventricular block induced during head-up tilt test.

A 71-year-old female with vasovagal near-syncope suffered from paroxysmal second-degree AV block during Holter monitoring. AV block was easily reproduced during head-up tilt test. She was successfully treated with a dual chamber pacemaker. This treatment is unusual and the role of cardiac pacing in patients with vasovagal symptoms is reviewed.

Usefulness of isoproterenol in the induction of clinical sustained ventricular tachycardia during electrophysiological study.

Electrophysiological testing remains the basic procedure in the assessment of life-threatening sustained ventricular tachycardias (VT). The predictive value of inducible VT depends on the baseline stimulation protocol and probably on some other factors, including automatic balance. We report the cases of four patients, with a history of myocardial infarction, who experienced recurrent episodes of syncope; the clinical aspects of the syncope were suggestive of syncopal VT. With a baseline protocol, electrophysiological testing only allowed the induction of well-tolerated non-sustained VT. Using the same stimulation protocol (rapid ventricular pacing or basal ventricular stimulation with 2 extra-stimuli), monomorphic sustained VT that had the same ECG morphology, as non-sustained VT, could only be induced while low doses of isoproterenol (1-2 micrograms/min) were being administered. In these cases, increased sympathetic tone appears to be prerequisite for a sustained VT reproducing the patients clinical symptoms and discomfort. To conclude, in some patients with recurrent symptoms, including syncope suggestive of ventricular arrhythmia, low-dose infusion of isoproterenol may facilitate the induction of of clinical sustained VT and increase the predictive value of electrophysiological testing. Possible mechanisms of ventricular arrhythmogenesis by isoproterenol are discussed.

[Traumatic myocardial infarction caused by lead shot]. / Infarctus du myocarde traumatique par plomb de chasse.

The authors report the case of a 32 year old woman who was shot with a shotgun. Acute inferior wall infarction was detected fortuitously on electrocardiography and coronary angiography showed occlusion of the right coronary artery with lead shot. The single coronary lesion, absence, of other cardiac complications (haemopericardium, cardiac perforation, ...) and the favourable outcome with conservative medical treatment has not been previously reported to the authors' knowledge.

[Malignant mitral valve prolapse: apropos of a case]. / Prolapsus valvulaire mitral malin: a propos d'un cas.

The authors report the case of a 67-year-old woman, with mitral valve prolapse, for more than 20 years. She recently complained of attacks of syncope and clinical ventricular tachycardia; ventricular fibrillation was induced during programmed stimulation. The patient seemed to be at high risk for sudden cardiac death, and was therefore treated with an automatic implantable defibrillator. The pathophysiology and risk factors of sudden cardiac death in mitral valve prolapse are discussed.

Unusual atrial pro-arrhythmic effect of flecainide: a contemporary review.

The authors report the case of a patient with drug-resistant atrial fibrillation, who developed, for more than 2 hours, a well-tolerated attack of palpitations, after taking 500 mg of flecainide acetate. The Holter monitoring demonstrated atrial flutter with 1:1 AV conduction and a ventricular rate at 220 bpm. This atrial pro-arrhythmic effect is rare and the mechanism is discussed.

[Major prolongation of the QT interval observed in the course of massive pulmonary embolism]. / Allongement majeur de l'intervalle QT observée lors d'une embolie pulmonaire massive.

The authors report the case of a 68-year-old woman who suffered from an acute massive pulmonary embolism. The common electrocardiographic findings were not observed, but rather an extreme QT prolongation. The patient has been successfully treated by thrombolysis. After a few days, the electrocardiogram normalized. These electrocardiographic changes have not yet been described in the medical literature.

[Chest pain and electrocardiographic changes in the presence of stenosis of the left common coronary artery]. / Angor et modifications électrocardiographiques en présence d'une sténose du tronc commun de l'artère coronaire gauche.

Twelve-lead electrocardiogram were studied in 40 consecutive patients with angiographic left main coronary artery disease. The ECG were analysed during chest pain. The most frequent pattern was a ST elevation (> 0.1 mV) in lead a VR alone or with ST depression (> 0.2 mV) in the anterior or lateral leads. In coronary artery disease patients, the 12-lead electrocardiogram at rest remains the best test to detect patients at higher risk for massive myocardial infarction or death.

Successful radiofrequency ablation of a true paraHissian accessory pathway.

Radiofrequency catheter ablation seems to become a first-line therapy for patients with paroxysmal tachycardias using an accessory pathway. We report the case of a 31-year-old woman who suffered from drug-resistant recurrent reciprocating tachycardia, using an uncommon accessory pathway. The 12-lead electrocardiogram in sinus rhythm showed the following characteristics: a positive delta waves in leads I, II, aVL, aVF, QRS axis = 0 degrees, R/S in lead V1 < 1, and a special QRS pattern in the precordial leads (QS or Qr in V1-V3 and QRS transition > V3). A deep septal parahissian accessory pathway has been localized using classic endocardial mapping procedures and has been confirmed during successful radiofrequency catheter ablation. Normal auriculo-ventricular conduction has been totally preserved. No complications or recurrence were observed during the follow-up. We have reviewed the electrophysiologic criteria to confirm this rare accessory pathway location.

[Myocardial revascularization using Vineberg's procedure; 23 years follow-up]. / Revascularisation myocardique par opération de Vineberg; un suivi de 23 ans.

The authors report the case of a patient followed up for 23 years after a double myocardial implantation of the internal mammary arteries (Vineberg technique) for unstable angina. The result of this procedure of surgical revascularisation has been very satisfactory to date. The authors believe this to be the longest follow-up reported in the medical literature.