[Prescriptions in cardiology]. / Comment je prescris aujourd'hui en cardiologie.

Prescriptions in cardiology have progressed from the often empirical and approximate approach used in the past to more rational approach based on the results of large clinical trials. For high blood pressure, bi- or even tri-therapy is often necessary. For coronary heart disease, betablockers, aspirin, calcium inhibitors, statins and converting enzyme inhibitors constitute the mainstay drugs. For myocardial infarction, the crucial point is to restore muyocardial perfusion as quickly as possible by thrombolysis or angioplasty. Polytherapy is required for heart failure. Finally, for atrial fibrillation, after anticoagulation, sinus rhythm can be restored with anticoagulant cover can be obtained with electrical shock or antiarrhythmic drugs.

[Value of combined coronary angioplasty and coronary angiography]. / Intérêt de l'angioplastie coronaire dans le même temps que la coronarographie.

Combined coronary angioplasty and coronary angiography is performed in most catheter laboratories and has become a routine procedure. The aim of this study was to assess its clinical results and economic value. This was a retrospective monocenter study performed over an 11 year period (1990-2000) which included 2,727 patients requiring coronary angioplasty after coronary angiography. The angioplasty procedure was performed at the same time as angiography (combined, n = 1,809) or after angiography (deferred, n = 631). Patients admitted for acute coronary syndromes not stabilised by pharmacological interventions were excluded from the study. The comparison of these two modes of angioplasty was based on primary success rates, complications, duration of hospital stay and hospital costs. The combined procedure was used progressively more frequently over the study period, increasing from 54% to 88% in 2000. The hospital clinical results (Success and complication rates) were comparable in the two groups. The predictive factors of failure were the year of the angioplasty procedure and occlusive lesions on multivariate analysis. The combined procedure was associated with a shorter hospital stay than deferred angioplasty (8.2 +/- 6.1 days versus 15.0 +/- 8.0 days, p = 0.0001) and with lower costs. The authors conclude that combined coronary angiography-angioplasty is as effective and as safe as deferred angioplasty. It is associated with a shorter hospital stay and lower hospital costs.

[Identification of unstable coronary atherosclerotic plaques]. / Identification des plaques d'athérosclérose coronaire instables.

The mechanisms of atherogenesis are better understood and the detection of atherosclerosis has improved with the different diagnostic methods currently available. However, it is almost impossible at present to differentiate high risk, unstable or vulnerable plaques from quiescent or stable plaques of atherosclerosis. This is a crucial problem given the banality of atherosclerosis on the one hand, and, on the other hand, the serious consequences (acute coronary syndromes, cerebrovascular accidents) of thrombotic occlusion at the site of an atherosclerotic plaque. It has now been established that the composition of the plaque is more important than the degree of stenosis, a fundamental concept in the risk of plaque rupture, precipitating the cascade of reactions leading to uncontrolled thrombosis. Consequently, new imaging techniques should address the problem of analysing the composition of atheromatous plaques. Endovascular ultrasonography, fast CT, angioscopy, nuclear imaging techniques and MRI are so many promising tools. However, non-invasive techniques should be distinguished from invasive ones. In all probability, it will be the former which will turn out to be the most useful diagnostic aid in pauci or asymptomatic patients. This article reviews the different imaging techniques under evaluation for the identification of risk of plaque rupture.

Talking effect and "white coat" effect in hypertensive patients: physical effort or emotional content?

Talking has been shown to increase blood pressure instantaneously in hypertensive patients and to contribute to the white coat effect. The effects of talking were compared with those of counting aloud in 64 patients with essential hypertension who were randomly assigned to a period of stress talking and a period of counting aloud (active periods), alternating with three periods of silence (control). The same monitor was used for office measurements and 24-hour ambulatory blood pressure analysis. Systolic/diastolic blood pressures increased significantly more during talking (163/110 mmHg) than during counting aloud (152/102 mmHg, both p < .0001) in both treated and untreated patients and in sustained and clinical hypertension. Talking had a residual effect on systolic blood pressure that lasted 5.8 +/- 0.1 minutes. The emotional content seemed to be the only cause of the talking effect. Its instantaneous and residual effects on blood pressure and heart rate should be considered when measuring these variables.

Clinical outcome following coronary angioplasty in dialysis patients: a case-control study in the era of coronary stenting.

BACKGROUND: Balloon coronary angioplasty has been reported to be ineffective in patients treated for end stage renal disease because of a high restenosis rate. OBJECTIVE: To compare the clinical outcome following coronary angioplasty with provisional stenting in dialysis versus non-dialysis patients. DESIGN: A case-control study. PATIENTS: Of 1428 consecutive patients who underwent coronary angioplasty, 100 (7%) were being treated for end stage renal disease. These were compared with 100 control patients matched for age, sex, coronary lesions, presence of diabetes mellitus, and rate of coronary stenting (40%). MAIN OUTCOME MEASURES: In-hospital and one year clinical outcome. RESULTS: The rates of procedural success (90% v 93%), in-hospital mortality (1% v 0%), stent thrombosis (0% v 0%), and Q wave myocardial infarction (0% v 1%) were similar in dialysis and non-dialysis patients. One year clinical outcome after coronary angioplasty was similar in the two groups in terms of clinical restenosis (31% v 28%) and myocardial infarction (6% v 2%), but cardiac death was more common in dialysed patients (11% v 2%, p < 0.03). CONCLUSIONS: Dialysis does not increase the risk of clinical restenosis after coronary angioplasty with provisional stenting. Coronary angioplasty is a safe and effective therapeutic procedure in selected dialysis patients with culprit lesions accessible to stenting. However, the one year survival is reduced in this high risk population.

[Aortic dissection among blacks. Report of 6 Congolese cases]. / La dissection aortique chez les Noirs. A propos de six cas congolais.

INTRODUCTION: The authors report on six cases of aortic dissection (AD). The work intended to bring out AD characteristics and attempt to define a profile of African patients who manifested this disease. The diagnosis of AD was determined on the basis of: clinical and radiological criteria (six cases); echocardiographic data (five cases); aortographic and surgical informations (two cases). PATIENTS AND METHODS: There were three males and three females with an average age of 40.2 years, with a variation of +/- 10.6 years (from 17 to 49). The frequency of AD was estimated at 1.8/10,000 admissions considering all causes and 5.4/10,000 for cardiovascular disease. Strain was the only triggering factor--noted in two cases (Observations 2 and 3). All patients suffered from severe arterial hypertension (AHT) of which there was one case of renovascular AHT based on the Takayasu arteritis. All symptoms and physical findings were the same described in literature. Operations were successful on two patients. The four unoperated patients died (tamponade: two cases, undetermined cause: two cases). CONCLUSION: The authors conclude as to the similarity of the AD charts described in the literature. However they stress the almost exclusive role of AHT in African studies series as well as that, in rare cases, of Takayasu's disease. They recommend preventing AD through the sustained and effective treatment of AHT.

[Coronary angioplasty in hemodialysis patients]. / Angioplastie coronaire chez l'hémodialysé.

The results of balloon coronary angioplasty are very disappointing in haemodialysis patients because of the high restenosis rate. On the other hand, the use of stents in this population had not previously been assessed. This retrospective study compared 63 coronary patients on haemodialysis with a référence group of 63 paired patients with respect to gender, age, and the necessity or not of stent implantation. There was a higher frequency of hypertension (79 vs 39%) and of hypertriglyceridaema (22 vs 8%) in the haemodialysis group than in the controls. However, there was no significant difference with respect to primary success rate of angioplasty (92 and 89% respectively), nor to the development of early cardiovascular complications (4% and 1.9% respectively). After a two-year follow-up, there was no significant difference in the restenosis rate in the haemodialysis patients (33%) compared with the controls (25%). Nevertheless, the mortality rate at 2 years was higher in the dialysis group (15%) compared with the reference group (3.5%, p = 0.03). However, this mortality rate was lower than that reported in the literature in haemodialysis patients after balloon angioplasty. Therefore, haemodialysis does not increase the risk of restenosis when an optimal angiographic results is obtained either by balloon angioplasty or by angioplasty with stenting. Coronary angioplasty is a safe and effective method of revascularisation in coronary haemodialysis patients when the lesions are accessible to stenting.

Detection of coronary restenosis by exercise electrocardiography thallium-201 perfusion imaging and coronary angiography in asymptomatic patients after percutaneous transluminal coronary angioplasty.

Noninvasive detection of restenosis in patients remaining asymptomatic after percutaneous transluminal coronary angioplasty (PTCA) remains a major clinical problem. The value of exercise electrocardiography (ECG) and exercise-redistribution thallium-201 single-photon emission computed tomography (SPECT) in detecting restenosis in such patients remains uncertain. Discordances between these tests and coronary angiography is a common situation. We studied 179 consecutive patients remaining asymptomatic after successful PTCA (208 vessels), who underwent 6 +/- 2 months of exercise ECG, SPECT, and coronary angiography. We sought to assess the diagnostic value of the noninvasive tests compared with coronary angiography, and identify the determinants of discordances between the tests. Restenosis (diameter stenosis >50%) was detected in 39% of patients and in 37% of vessels. The overall sensitivity, specificity, and accuracy for exercise ECG and SPECT in detecting restenosis in individual vessels were, respectively, 53% versus 63% (p = 0.06), 59% versus 77% (p = 0.0001), and 57% versus 72% (p = 0. 0001). On multivariate analysis, positive exercise ECG was associated with higher heart rate response (p = 0.02), incomplete revascularization (p = 0.004), and angiographic restenosis (p = 0. 03), whereas positive SPECT was associated with incomplete revascularization (p = 0.02), infarct-related artery PTCA (p = 0.01), and angiographic restenosis (p = 0.0001). Accuracies of the 2 tests were not significantly different in patients with incomplete revascularization or PTCA of an infarct-related vessel. Overall, SPECT is more accurate than exercise ECG in detecting asymptomatic restenosis. Nevertheless, incomplete revascularization and PTCA of an infarct-related artery could cause reversible perfusion defects regardless of restenosis, reducing the diagnostic value of SPECT in such patients.

Influence of SIN-1 on platelet Ca2+ handling in patients with suspected coronary artery disease: ex vivo and in vitro studies.

The 3-morpholinosydnonimine (SIN-1) generates both nitric oxide (NO) and superoxide anion (O2-). It elicits dose-dependent vasodilation in vivo, in spite of the opposite effects of its breakdown products on vascular tone and platelet aggregation. This study was designed to investigate the influence of intravenous SIN-1 injection on platelet Ca2+ handling in patients undergoing coronary angiography. SIN-1 administration reduced cytosolic [Ca2+] in unstimulated platelets by decreasing Ca2+ influx. It attenuated Ca2+ mobilization from internal stores evoked by thrombin or thapsigargin. In vitro studies were used as an approach to investigate how simultaneous productions of NO and O2- from SIN-1 modify thrombin- or thapsigargin-induced platelet Ca2+ mobilization. Superoxide dismutase, the O2- scavenger, enhanced the capacity of SIN-1 to inhibit Ca2+ mobilization but catalase had no effect. This suggests that the effects of SIN-1 on platelet Ca2+ handling resemble those of NO, but are modulated by simultaneous O2- release, independently of H2O2 formation.

[New thrombolytic agents in myocardial infarction]. / Nouveaux agents thrombolytiques dans l'infarctus du myocarde.

Myocardial infarction is the result of thrombotic coronary artery occlusion. Although present-day thrombolytics have major value by increasing the frequency of reopening of arteries responsible for myocardial infarction, by preserving myocardial function and, thereby, significantly reduce mortality. Nevertheless, they are subject to the following limitations: 1) excellent arterial partency is only obtained in 50% of cases: 2) reocclusion occurs in 5 to 10% of cases; 3) severe complications such as cerebral haemorrhage are observed in about 0.5% of cases. Therefore, the search to improve thrombolytic agents is intense. This article reports the recent advances in concept and production of new thrombolytic agents. The most recent results concern the production of mutants of T-PA (tissue plasmogen activator). Of these mutants, the reteplase (r-PA) has already received authorization for its commercialisation. Other t-PA mutants under development (phase 3) include TNK-t-PA and lanoteplase. Over the last few years, there has been renewed interest in staphylokinase. The results of the initial clinical trials with this agent have also been reported. Paradoxically, the mode of action of thrombolytic agents has an inherent pro-thrombotic effect. This explains some of the interest for anti-thrombotic agents as an adjuvant treatment of thrombolysis. The initial results of the association of thrombolytics with new glycoprotein IIb/IIIa platelet inhibitors and anti-thrombin agents are reported.

The heparin management test: a new device for monitoring anticoagulation during coronary intervention.

Whole blood coagulation analysers are widely used during percutaneous coronary interventions. The precise degree of anticoagulation in patients is important in this setting. The aim of this investigation was to compare the results obtained with ACT (Hemochron) and HMT, the Heparin Management Test (TAS) in patients undergoing percutaneous coronary interventions. Patients (n = 100) were enrolled prospectively. Each patient received 10,000 units of heparin. At the end of the procedure, the mean ACT was 284+/-31 seconds and the mean HMT was 292+/-33 seconds. The correlation between the two methods was highly significant (r = 0.64, p<0.001). The HMT correlates well with ACT values in patients undergoing percutaneous coronary interventions. Its use in the management of these patients should be considered.

Late results with bioprosthetic valves in the elderly.

AIM: We report the long-term outcome of aortic and mitral bioprostheses in patients over 65 years of age at the time of implantation. The aim was to determine actuarial patient survival, causes of death, and the rate of documented primary structural deterioration. METHODS: One hundred ten patients > or = 65 years of age (mean, 73.4; range, 65-82) underwent successful bioprosthetic valve replacement (aortic, n = 71; mitral, n = 32; both, n = 7) from 1979 to 1985. The valve was pericardial in 39 cases and porcine in 78. The mean follow-up was 8.5 years (101.9 months-total; 934 patient-years; range, 2 months to 15 years). RESULTS: Actuarial patient survival was 79.6% (71-86) at 5 years and 62.4% (52-71) at 10 years. Forty-four patients died, 21 from valve-related causes and 23 from other causes. Thirteen patients (11.8%) had reoperation for valve-related complications: 10 structural deteriorations, 2 paravalvular leaks, and 1 case of endocarditis. One surgical death occurred (7.7%). Twenty-six percent of the patients were receiving anticoagulants because of atrial fibrillation, and 6.4% developed severe bleeding (2.9% patient-years). CONCLUSIONS: Long-term follow-up of these patients > 65 years of age, undergoing bioprosthetic value replacement surgery revealed a low rate of documented primary structural deterioration (0.95% per patient-year), a low mortality rate on reoperation (7.7%), and a high mortality rate due to non-value-related causes (52.3%).

[Staphylokinase]. / La staphylokinase.

Myocardial infarction is due to thrombotic occlusion of a coronary artery. Current thrombolytic agents have demonstrated their major value by inducing a significant reduction of mortality, but they nevertheless present certain limits: 1) excellent arterial patency is obtained in only about 50% of cases; 2) reocclusions persist in 5 to 10% of cases; 3) very severe complications, such as cerebral haemorrhages, have not disappeared (about 0.5% of cases). There is therefore a large field of action for development of the optimal thrombolytic agent. Research concerning staphylokinase, classified among third generation thrombolytic agents, is therefore situated in this context. Staphylokinase is a protein known to possess profibrinolytic properties for more than four decades, but has been the subject of renewed interest over recent years. This article reviews the characteristics, mechanism of action and fibrinolytic properties of staphylokinase. It recalls the main results obtained in animal models and summarizes the main clinical trials in man.

Comparison of activated clotting times to heparin management test for adequacy of heparin anticoagulation in percutaneous transluminal coronary angioplasty.

The aim of this study was to compare the activated clotting time (ACT) obtained with the Hemochron device and the Heparin Management Test (HMT) on a new automated whole-blood coagulometer, the Thrombolytic Assessment System, in patients undergoing angioplasty. Fifty patients undergoing balloon angioplasty were prospectively enrolled. The mean ACT after a 10,000 unit bolus of heparin was 283 +/- 39 sec at the end of the procedure. The mean HMT after 10,000 units of heparin was 286 +/- 31 sec at the end of the procedure in the same patients. The correlation between the two methods was significant (r = 0.6; P < 0.01). The HMT appears to correlate well with standard values obtained with the Hemochron ACT monitor in patients undergoing percutaneous transluminal coronary angioplasty.

Late coronary angioplasty and ventricular late potentials.

To assess the effect of successful late coronary angioplasty of an occluded infarct-related artery on the prevalence of ventricular late potentials, signal-averaged electrocardiograms were recorded in 123 consecutive patients surviving a first acute myocardial infarction (58 with and 65 without mechanical reperfusion of the occluded coronary artery). Multivariate analysis showed that successful reperfusion by late angioplasty of the infarct artery contributes to a decrease in the prevalence of late potentials.