Early increase of von Willebrand factor predicts adverse outcome in unstable coronary artery disease: beneficial effects of enoxaparin. French Investigators of the ESSENCE Trial.

BACKGROUND: The pathogenesis of unstable angina and non-Q-wave myocardial infarction is still poorly understood, and early evaluation of prognosis remains difficult. We therefore studied the predictive value of 5 biological indicators of inflammation, thrombogenesis, vasoconstriction, and myocardial necrosis, and we examined the effects of enoxaparin and unfractionated heparin on these markers after 48 hours of treatment. METHODS AND RESULTS: Sixty-eight patients with unstable angina or non-Q-wave myocardial infarction randomized in the international ESSENCE trial participated in this French substudy. C-reactive protein, fibrinogen, von Willebrand factor antigen, endothelin-1 and troponin I were measured on admission and 48 hours later. The composite end point of death, myocardial infarction, recurrent angina, or revascularization was significantly lower at 14 and 30 days of follow-up in patients allocated to enoxaparin compared with unfractionated heparin. All acute-phase reactant proteins were elevated on admission and increased further at 48 hours. Multivariate analysis demonstrated that the rise of von Willebrand factor over 48 hours was a significant and independent predictor of the composite end point at both 14 days and 30 days. Moreover the early increase of von Willebrand factor was more frequent and more severe with unfractionated heparin than with enoxaparin (mean change was +8.7+/-8.8% with enoxaparin versus +93.9+/-11.7% with unfractionated heparin, P<0.0001). The other clinical and biological variables did not predict outcome. CONCLUSIONS: In patients with unstable angina or non-Q-wave myocardial infarction, the acute-phase proteins increase over the first 2 days despite medical treatment. The early rise of von Willebrand factor is an independent predictor of adverse clinical outcome at 14 days and at 30 days. Enoxaparin provides protection as evidenced by the reduced release of von Willebrand factor, which represents a favorable prognostic finding.

[[Doppler echocardiography in the diagnosis of tri-atrial heart in adults]. / Apport de l'échocardiographie-doppler dans le diagnostic du coeur triatrial de l'adulte.

The authors report a case of isolated and well tolerated cor triatriatum in a 38-year old man without significant history admitted for aetiological diagnosis of atrial fibrillation. Echocardiography displayed the left intra-atrial septum and the openings of the 4 pulmonary veins in the proximal chamber, but there was no evidence of associated anomaly. Colour-coded doppler examination visualized a single systolo-diastolic trans-septal jet. As the maximum velocity of the jet at pulsed doppler velocimetry was 1.1 m/s, the maximum instantaneous gradient could be estimated at 5 mmHg. The mean gradient was estimated at 2.6 mmHg, which showed that the ostium caused little stenosis. All these data were confirmed by cardiac catheterization. Since the malformation was well tolerated, both functionally and haemodynamically, it was decided not to operate.

[Asymptomatic coronaro-cardiac fistula. Apropos of a case]. / Fistule coronaro-cardiaque asymptomatique. A propos d'un cas.

The case of a 20 year old woman with a right coronary-right atrial fistula is reported. The diagnosis was made during investigation of a continuous murmur and the tolerance was excellent. Aortic root angiography demonstrated a fistula between the initial part of the right coronary artery and a right heart cavity. Selective coronary angiography visualised pseudo-aneurysmal dilatation of the first segment of the right coronary artery, the calibre and trajectory of which was then normal. The medical literature suggests surgical correction even in asymptomatic cases because of the risk of spontaneous complications (cardiac failure 15 p. 100, endocarditis 7 p. 100, infection 4 p. 100). Since 1968, there has been no operative mortality in 145 subjects with isolated coronaro-cardiac fistulae without cardiac failure. In the case presented, the fistula was successfully closed under cardiopulmonary bypass and endoaneurysmorrhaphy was performed to remodel the lumen of the right coronary artery.