[CONTRIBUTION OF CARDIAC CATHETERIZATION TO THE DIAGNOSIS AND TREATMENT OF CORONARY HEART DISEASE BEFORE AGE 40]. / APPORT DU CATHÉTÉRISME CARDIAQUE DANS LE DIAGNOSTIC ET LE TRAITEMENT DE LA MALADIE CORONARIENNE AVANT 40 ANS.

Coronary artery disease is the most frequent heart disease in our population. Its pathogenesis is well known and the first manifestation of the disease can occur in young adults. The main cause is atherosclerosis. The prevention and treatment of cardiovascular risk factors are key elements. The clinician's diagnosis is crucial before coronary arteriography, since the rate of percutaneous procedures decreases with the gravity of the starting diagnosis.

High prevalence of abdominal aortic aneurysm in patients with three-vessel coronary artery disease.

OBJECTIVES: Currently, the prevalence of abdominal aortic aneurysm (AAA) in patients with coronary artery disease (CAD) and the correlation between CAD severity and AAA prevalence are not clearly known. We conducted a prospective study to determine the prevalence of AAA in patients undergoing coronary angiography and to determine the risk factors and a coronary profile associated with AAA. METHODS: Over an 18-month period, abdominal aortic ultrasound was performed on 1,000 patients undergoing coronary angiography for suspected or known CAD, or prior to valve surgery. Clinical characteristics and coronary profile were collected from the patients. RESULTS: The overall number of previously repaired, already diagnosed, and new cases of AAA in the study population was 42, yielding a prevalence of 4.2%. Among the patients with newly detected AAAs, only two had an AAA diameter of >54 mm and were therefore treated surgically. In men aged ≥ 65 years, the prevalence reached 8.6%, while in men with three-vessel CAD it was 14.4%. Multivariate analysis showed that age ≥ 65 years (p = .003), male gender (p = .003), family history of AAA (p = .01), current smoking (p = .002), and three-vessel CAD (p < .001) were significantly associated with a higher prevalence of AAA. CONCLUSION: The prevalence of AAA was high in men aged ≥ 65 years and in those with three-vessel CAD regardless of age. While our findings do not prove the cost-effectiveness of screening for AAA in these high risk patients, they do support the usefulness of a quick ultrasound examination of the abdominal aorta during routine transthoracic echocardiography in such patients.

[CT coronary angiography for the diagnosis of coronary heart disease]. / Contribution du scanner coronaire au diagnostic de maladie coronarienne.

Coronary computed tomography is an emerging technique for the diagnosis of coronary heart disease. Based on a clinical case, we discuss the diagnostic evaluation of chest pain and the role of coronary CT.

Identification of protein biomarkers associated with cardiac ischemia by a proteomic approach.

Angina is chest pain induced by ischemia of the heart muscle, generally due to obstruction or spasm of the coronary arteries. People that suffer from average to severe cases of angina have an increased percentage of death before the age of 55, usually around 60%. Therefore, prevention of major complications, optimizing diagnosis, prognosis and therapeutics are of primary importance. The main objective of this study was to uncover biomarkers by comparing serum protein profiles of patients suffering from stable or unstable angina and controls. We identified by non-targeted proteomic approach and confirmed by the means of independent techniques, the differential expression of several proteins indicating significantly increased vascular inflammation response, disturbance in the lipid metabolism and in atherogenic plaques stability.

[Multimodal cardiovascular imaging before aortic valve transcatheter replacement]. / L'imagerie cardiovasculaire multimodalités avant l'implantation d'une prothèse valvulaire aortique par voie percutanée.

Calcified aortic valve stenosis is the most frequent valvular heart disease in developed countries with a very poor outcome when symptoms develop. However, several of these patients are denied for surgery. The main reasons are their advanced age (elderly patient), co-morbidities, technical limitations and a very high surgical risk. It is currently possible to propose a Transcatheter Aortic Valve Implantation (TAVI). After selection of candidates, the feasibility of the intervention is analysed. The size of the aortic bioprosthesis must be selected according to the cardiac anatomy. Several cardiac imaging modalities (echocardiography, computed tomography and cardiac MRI) can be used to identify unsuitable situations. Heavy calcifications or tortuosity can thwart the retrograde approach use. The sub-clavian arteries (for the CoreValve) and trans-apical approach (for the Edwards-Sapien) constitute alternatives ways.

[Wellens syndrome: a poorly known yet significant electrocardiographic entity]. / Une entité electrocardiographique peu connue, mais pourtant importante aux urgences ... le syndrome de Wellens.

We report the case of a 54-year-old patient admitted to an emergency department, because of a thoracic pain suspicious for angina pectoris. Although the patient had become asymptomatic on admission, his electrocardiogram presented abnormalities (biphasic T waves in V1 to V4 ) which prompted a diagnosis of unstable angina.This electrocardiophic pattern is known as Wellens' syndrome.

[Interventional options in modern treatment of hypertrophic obstructive cardiomyopathy]. / Options interventionnelles en matière de traitement moderne de la cardiomyopathie hypertrophique obstructive.

Obstructive hypertrophic cardiomyopathy is a complex pathology. The understanding of its physiopathology and, notably, of the SAM phenomenon (Systolic Anterior Motion), is crucial for all available treatments. Amongst the most efficient therapies, one can cite the septal myectomy and its most recent technical updates, as well as the alcohol septal ablation. The choice between these two methods depends on the general state of the patient, the thickness of the interventricular septum and the coronary anatomy of the patients.

[Adherence to antiplatelet therapy in patients with coronary artery disease]. / Adhésion thérapeutique aux antiagrégants chez le patient coronarien.

Clinical benefit of antiplatelet therapy is established for cardiovascular disease and percutaneous coronary intervention (PCI). Dual antiplatelet therapy is used to optimize platelet inhibition. However, cardiovascular events still occur. Aspirin/clopidogrel resistance and poor compliance are the main factors implied in recurrent events. Compliance to dual antiplatelet therapy is particularly relevant during the first 6 months following acute coronary syndromes and PCI. Furthermore, several studies have shown association between antiplatelet resistance and poor compliance. Additionally, late (1 month to 1 year) and very late (> 1 year) stent thromboses are intimately linked to interruption of antiplatelet treatment. In this article we review the latest data about compliance, resistance and recommendations regarding antiplatelet therapy.

[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.

[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.

[Monoclonal antibodies in cardiology]. / Anticorps monoclonaux en cardiologie.

Clinical efficacy of antiplatelet agents administration to reduce ischemic complications has supported the concept of atherothrombosis and plaque rupture. Specifically, administration of monoclonal antibody against platelet membrane receptor glycoprotein IIb/IIa was shown to be highly effective whenever percutaneous intervention is performed in the setting of unstable coronary syndrome. The in-hospital use of glycoprotein IIb/IIIa is unanimously recommended in these situations.

[Incidence of restenosis and cardiac events after coronary angioplasty in diabetic patients: reduction by systemic pharmacological approaches]. / Risque de resténose et d'evénements cardiaques après angioplastie coronaire chez le patient diabétique: réduction par des approches pharmacologiques systémiques.

Various systemic pharmacological approaches have been evaluated to reduce the risk of restenosis after coronary angioplasty, with or without stent, in the general population and in diabetic patients who are at increased risk for such complication. The aim of the present paper is to describe the effects of the main pharmacological classes on the risk of restenosis, the need for new revascularisation procedures and the incidence of major clinical events (MACE: death, myocardial infarction, revascularisation). We will analyse the role of antiplatelet agents, omega-3 fatty acids, statins, anti-inflammatory compounds, immunomodulators, anti-oxidants, glitazones and, finally, classical antidiabetic drugs such as metformin and insulin. Whenever possible, we will focus our attention on the results obtained in the diabetic population.

[Elevation of cardiac biomarkers after strenuous physical exertion]. / Elévation des biomarqueurs cardiaques après un effort physique intense.

We present the case of a patient who felt faint after a strenuous exercise. A coronary angiography was performed because of an elevated level of troponin, but it failed to demonstrat any significant coronary stenosis. We discuss the effect of strenuous exercise on cardiac biomarkers. Most previous published studies involved young trained populations. The frequency of these abnormalities in older, less trained people is unknown. Moreover, the possible impact of these abnormalities on mid- or long-term outcome is a matter of debate. Seniors practising intensive sport activities should systematically be submitted to a cardiological evaluation.

[Prevention of restenosis and of cardiac events after coronary angioplasty in diabetics]. / Prévention de la resténose et des accidents cardiaques après angioplastie coronaire chez le diabétique.

Various systemic pharmacological approaches have been evaluated to reduce the risk of restenosis and clinical complications after coronary angioplasty, with or without stent, a main objective in the high risk diabetic population. The aim of the present paper is to describe the effects of the main pharmacological classes on the risk of restenosis, the need for new revascularisation procedures and the incidence of major clinical events (MACE: death, myocardial infarction, revascularisation). We will analyse successively the role of antiplatelet agents, omega 3 fatty acids, statins, anti-inflammatory compounds, immunomodulators, anti-oxidants and inhibitors of the renin-angiotensin system. Whenever possible, we will focus our attention on the results obtained in the diabetic population.

[Benefit-risk ratio of coronary drug-eluting stents: 2nd part: evaluation in the diabetic population]. / Rapport bénéfice/risque des endoprothèses coronaires pharmaco-actives. 2ème partie: analyse dans la population diabétique.

The diabetic patient is at high risk of coronary heart disease. He/she can benefit of revascularisation procedures, even if he/she is exposed to a higher incidence of complications after a coronary artery bypass graft or a percutaneous transluminal coronary angioplasty. The use of drug-eluting stents--paclitaxel (PES) or sirolimus (SES)--dramatically reduces the risk of restenosis as compared to bare-metal stents; nevertheless, the rate of restenosis remains almost double in diabetic patients compared to that observed in non-diabetic subjects. However, the risk of (very) late thrombosis is higher with drug-eluting stents than with bare-metal stents, in the diabetic population as in the non-diabetic population. Altogether, among diabetic patients, the incidence of major cardiovascular events is significantly reduced with drug-eluting stents. This global clinical benefit essentially results from a diminution of revascularisation procedures rather than from a reduction of myocardial infarcts or cardiovascular deaths. Comparison between SES and PES gives discordant results. Indeed, while the loss of intra-stent lumen is more important with PES than with SES, PES are associated with a lower rate of major cardiovascular events than SES. Efficacious antiplatelet therapy in the long run is mandatory in all diabetic patients treated with drug-eluting stents.

[Benefit-risk ratio of coronary drug-eluting stents. 1st part: evaluation in the global population]. / Rapport bénéfice/risque des endoprothèses coronaires pharmaco-actives. 1ère partie: analyse dans la population générale.

Coronary drug-eluting stents (DES) are increasingly used in interventional cardiology. Stents coated with pharmacological substances such as sirolimus or paclitaxel, capable of reducing endothelial proliferation, have been proposed to replace bare-metal stents (BMS) in order to reduce the risk of restenosis. The survey of the literature confirms a major and significant reduction in the risk of restenosis with both sirolimus and paclitaxel DES as compared to BMS in the global population. This effect leads to a diminished requirement for new revascularisation procedures. However, such DES may increase the risk of very late stent thrombosis, presumably due to a defect of endothelialisation, which requires long-term effective antiplatelet therapy. The impact on major clinical coronary events shows no significant difference in mortality between DES and BMS. However, the incidence of myocardial infarct may be, slightly but significantly, reduced with sirolimus DES. In a next paper, the same analysis will be specifically performed in the diabetic population, which is well known to be at high risk of coronary heart disease, but is also expected to particularly benefit from DES.

[Antiplatelet therapy: should it be withdrawn before any invasive procedure?]. / Antiagrégants: doit-on les arrêter avant un acte invasif?

Antiplatelet therapy is the leading therapy for the primary and secondary prevention for the atherosclerotic arterial disease. The practical question of withdraw alavoiding or continuation of oral antiplatelet agents accurs currently before any invasive procedure. It is important to compare the relative thrombotic vs hemorrhagic risk. For most interventions, it is recommended to continue antiplatelet therapy. It is particularly important in patients who benefited from drug-eluting stents where the thrombotic risk is major.

[Strategies to shorten the time from urgent admission to coronary angioplasty: a recent publication in the New England Journal of Medicine]. / Strategies visant à diminuer le délai entre l'admission aux urgences et l'angioplastie coronaire: à propos d'un article rècent du New England Journal of Medicine.

A recent publication in New England Journal of Medicine stresses the fact that the mere presence of a coronarography equipment to dilate acute myocardial infarction is not sufficient to obtain the opening of the related myocardial infarction artery in due time.

[Clinical case of the month. Pulsus alternans: a rare semiologic sign of severe left ventricular dysfunction]. / Le cas clinique du mois. Le pouls alternant: un élément sémiologique rare de dysfonction ventriculaire gauche sévère.

A paradigmatic case of pulsus alternans observed during exploration of a severe aortic valve disease is reported. Pulsus alternans is a rare semiologic sign of severe left ventricular dysfunction and the mechanisms of its appearance are discussed.

[New therapeutic guidelines in cardiology]. / Actualités thérapeutiques en cardiologie.

Cardiovascular diseases are the leading cause of mortality in the so-called industrial countries. An appropriate management is mandatory and its modalities should be known and applied by physicians. European and American recommendations are regularly published and updated. They are available on the web sites of the European Society of Cardiology (www.escardio.org), the American Heart Association (www.aha.org) and the American College of Cardiology (www.acc.org This article describes the recent therapeutic options of some cardiovascular diseases, especially coronary artery disease, valvular diseases, atrial fibrillation and implantable defibrillator, but is far to be exhaustive.