[Evaluation about patient's knowledge on their direct oral anticoagulants treatment]. / Évaluation de la connaissance des patients de leur traitement par anticoagulant oral direct (AOD).

AIM OF THE STUDY: Patient's knowledge about their treatment is poor, generally speaking. New oral anticoagulants are easier to use compared to antivitamin K, and they are going to increase. This simplification can underestimate their high potential risk. We have assessed patient's knowledge about their direct oral anticoagulants. METHODS: It was a quantitative, observational, multicentric, prospective study, on 50 patients on Direct Oral Anticoagulants. They have been included from November 2015 to February 2017, in Île-de-France. They were needed to be aged more than 18years old, whatever was: the reason of this treatment, the beginning of it, the molecule, the existence or not of antivitamin K before. Their knowledge was assessed by a survey, realised by a unique investigator. The primary outcome was to reach more than 80% good answers to the survey. Secondary outcomes were to identify factors than can influence knowledge. RESULTS: Among fifty patients, nine (18%) reached a goal over or equal to 80%. They knew the name of their medicament in 58% of cases, and the indication in 72% of cases. They could identify hemorragic signs in more than 70% of cases. In case of hemorragic sign, 94% of them were going to see a doctor. Thrombosis signs were less knew. None of the factors, excepted their profession, was different in the two populations (P=0,01). CONCLUSION: This study showed the few rate of patient knowing their oral anticoagulants treatment perfectly, and their need to improve it. It could make professional healthcare aware to this problematic.

Infective endocarditis: Clinical presentation, etiology, and early predictors of in-hospital case fatality.

OBJECTIVE: We aimed to assess the clinical presentation, microbial etiology and outcome of patients presenting with infective endocarditis (IE). PATIENTS AND METHODS: We conducted a four-year retrospective study including all patients presenting with IE. RESULTS: We included 121 patients in the study. The median age was 74.8years. Most patients had native valve IE (57%). Staphylococcus aureus accounted for 24.8% of all IE. Surgery was indicated for 70 patients (57.9%) but actually performed in only 55 (44.7%). Factors associated with surgery were younger age (P=0.002) and prosthetic valve IE (P=0.001). Risk factors associated with in-hospital mortality were diabetes mellitus (OR=3.17), chronic renal insufficiency (OR=6.62), and surgical indication (OR=3.49). Mortality of patients who underwent surgery was one sixth of that of patients with surgical indication who did not have the surgery (P<0.001).

[Characteristics of the population hospitalized for advanced and terminal heart failure and experiences in palliative caring in the Intensive Care Unit of cardiology]. / Caractéristiques et prise en charge des patients hospitalisés pour insuffisance cardiaque terminale ayant fait l'objet d'une limitation de soins en unité de soins intensifs cardiologiques.

PURPOSE: Advanced heart failure incidence is in progression. Palliative care access remains difficult due to its unpredictable course. The aim of this study was to describe the characteristics of patients admitted in Cardiology Intensive Care Unit for advanced heart failure who received palliative care and compare them to the whole population of acute heart failure hospitalized in the same period. PATIENTS AND METHODS: The patients hospitalized for acute heart failure were retrospectively included from 2009 to 2013. We identified among them those who received palliative care. Specific caring was decided in pluridisciplinary meeting. RESULTS: On 940 patients included, 42 patients (4.5%) receive palliative care. Ischemic heart disease was the main etiology (n=19; 45.2%). Right ventricular dysfunction (n=34; 80.9%) was associated with supra-ventricular arrhythmia (n=28; 66.7%). Twenty-eight patients (57.1%) have died in hospital, 9 (21.4%) were referred to a palliative care unit and 8 (19.1%) was discharged or referred to a rehabilitation center. Time between inclusion and death was 6 days on average. Intra-hospital mortality in control group was 6.8%. CONCLUSION: Palliative care in cardiology is uncommon and has often been too late because of its poor adaptability to advanced heart failure. It is, as consequence, necessary to identify the prognostic factors of these patients in order to propose a personalized care and to adjust the intensity of care ahead of the terminal evolution of heart failure.

[Planimetric measurement of the regurgitant orifice area using tridimensional transoesophageal echocardiography for aortic regurgitation, reproducibility and feasibility]. / Validation de la reproductibilité de la mesure de la surface de l'orifice régurgitant par planimétrie dans l'insuffisance aortique : une étude préliminaire d'échocardiographie trans-œsophagienne tridimensionnelle.

BACKGROUND: Aortic regurgitation is mainly evaluated by trans-thoracic echocardiography using multi-parametric qualitative and semi quantitative tools. All those parameters can fail to meet expectations, resulting in an imperfect diagnostic reliability and assessment of aortic regurgitation severity can be challenging. OBJECTIVES: We sought to evaluate feasibility and intra- and inter-observer reproducibility of aortic regurgitant orifice area measured by planimetry with tridimensional trans-esophageal echocardiography on patients with at least grade 2/4 aortic regurgitation. PATIENTS AND METHODS: Consecutive patients with at least grade 2/4 aortic regurgitation measured by trans-thoracic echocardiography and referred for trans-esophageal echocardiography for any reason were included. Planimetric reconstructions of regurgitant orifice area were studied and reproducibility indexes between senior and junior observers were calculated. RESULTS: Twenty-three patients were included in this study. Intra- and inter-observer reproducibility were excellent with an ICC of 0.95 [0.88-0.98], P<0.0001 and 0.91 [0.79-0.96], P<0.0001, respectively. Mean length of the measurement was 6.6±0.9min [CI95% 6.23-7.01]. CONCLUSION: Planimetric measurement of the aortic regurgitant orifice using tridimensional trans-esophageal echocardiography seems to be feasible and has great intra- and inter-observer reproducibility. Reconstruction durations were compatible with a daily use. There is a need now to investigate the reliability of this measurement as compared with the reference technique.

[Anemia in congestive heart failure]. / L'anémie dans l'insuffisance cardiaque.

UNLABELLED: Anemia is a common disorder in congestive heart failure and an independant prognostic factor. The aims of this study are to evaluate the prevalence of anemia among a population of in-hospital congestive heart failure patients, to compare anemic patients (A) with non anemic patients (NA) and to study their cares. RESULTS: One hundred and thirty-two patients, 70 men (53%), et 62 women (47%) are enrolled. Mean age is 76.4+/-13.5 years. The prevalence of anemia (WHO criteria) is 49%. Patients A are older than NA: 79.1+/-13.8 years versus 73.8+/-12.9 years (p=0.025), renal function is more altered in A than in NA, creatinine clearance is 56.5 ml/min (A) versus 76.2 ml/min (NA) (p=0.003). Ejection fraction (EF) is lower in A than in NA: 35.1+/-15.3% versus 50.9+/-15.9%, (p<0.0001.) Anemia is less frequent in preserved EF (28%) than in low EF (63%) (p<0.0001). Hospitalization duration is longer in A than in NA: 10.7+/-10.1 days versus 6.9+/-3.7 days (p=0.005). There are more re hospitalized patients among A than NA: 38 versus 10 (p=0.0001). There is a significant difference of survival of NA versus A at day 614 (p=0.03). CONCLUSION: Anemia is frequent in our population, and is associated with others prognostic factors and comorbidity.

[The contribution of computed tomography coronary angiography in Kawasaki disease in adult patients. Report of two cases]. / Apport du scanner coronaire dans la prise en charge de la maladie de Kawasaki chez l'adulte. A propos de deux cas.

OBJECTIVES: During the past few years, multislice computed tomography coronary angiography has made great progress in terms of spatial and temporal resolution. Results on detection and quantification of stenoses are excellent. We found interesting reporting its achievements in aneurismal coronaropathies such as the Kawasaki disease. METHODS: We searched for young adults with Kawasaki disease who had a multislice computed tomography coronary angiography available. Several hospitals in the Paris area have been contacted and only two observations have been kept. RESULTS: Computed tomography provided higher performance than coronarography for the measurement of the real diameter of an aneurism taking into account the mural thrombus, evaluation of its links with the collateral branches and the other aneurisms, assessment of the development of recanalized vessels and the degree of development of collateral vessels, and visualization of non-circulating aneurisms which were not detected with coronary angiography. In addition, the evaluation of the location and the degree of the stenoses by the computed tomography matched the coronary angiography data. It was not possible to conclude with this observations that the computed tomography is better for the diagnostic of Kawasaki disease. CONCLUSION: Multislice computed tomography coronary angiography will be likely more and more used to detect and follow coronary anomalies in case of Kawasaki disease among teenagers and young adults. It is recommended for monitoring medium or large aneurisms in order to evaluate their progression to stenosis.

[Treatment of stable angina. Coronary angioplasty versus medical treatment]. / Traitement de l'angor stable. Angioplastie coronaire versus traitement médical.

Stable angina is a common clinical condition in everyday practice. Several studies (ACME, MASS, RITA 2) compared the efficacy of angioplasty with medical management in this context with concordant results: significant reduction in the frequency of angina and improved exercise capacity, without reduction in the number of serious events (death, infarction). Even though developments in the field of angioplasty have provided better clinical results, especially with the use of stents, the indication of dilatation should be clearly defined by a series of clinical and angiographic parameters. Although resistance to well conducted medical treatment is an indication for revascularisation when possible, the indications should be reconsidered if persistent ischaemia with medical therapy has not been proved.

[Angioplasty with stent of the common trunk of the left coronary artery with abnormal origin at the level of the right anterior sinus and with a retro-aortic trajectory]. / Angioplastie avec stent d'un tronc commun de la coronaire gauche à naissance anormale au niveau du sinus antéro-droit et à trajet rétro-aortique.

The authors report a case of angioplasty with implantation of a stent in an anomalous left main coronary artery arising from the right anterior sinus of Valsalva with a retro-aortic trajectory. The introduction of stenting has made angioplasty of anomalous coronary arteries a possible alternative to surgery with the reserve of a high risk of restenosis when the lesion is distal and situated at a bifurcation.

[Transluminal coronary angioplasty in the acute phase of myocardial infarction]. / Place de l'angioplastie transluminale des coronaires dans le traitement de l'infarctus du myocarde à la phase aiguë.

The objective of the treatment of myocardial infarction is to reestablish patency of the occluded artery as soon as possible. Two methods have been validated: intravenous thrombolysis which is easy to perform, and transluminal coronary angioplasty requiring expensive infrastructures and a skilled medical team but which has a higher success rate of restoring arterial patency. Angioplasty is indicated in cardiogenic shock and cases in which there is diagnostic uncertainty or a contraindication to thrombolysis. In addition, its superiority over thrombolysis has been clearly demonstrated in the following indications: 1) primary angioplasty if proper facilities with an experienced team are available in less than 45 minutes and 2) after failed thrombolysis (rescue angioplasty). The use of stents improves the results of primary angioplasty. Angioplasty and thrombolysis are not rival techniques: the choice depends on local conditions (proximity to a catheterization laboratory with a trained medical team) and the clinical context (presence of "high-risk" criteria). Their association (prehospital thrombolysis followed by immediate angioplasty) is the object of prospective clinical trials.

Acute hemodynamic interaction of aspirin and ticlopidine with enalapril: results of a double-blind, randomized comparative trial.

BACKGROUND: Coprescription of aspirin and ACE inhibitors is frequent in heart failure caused by coronary artery disease. Negative interaction between aspirin and enalapril has been reported, presumably through inhibition by aspirin of ACE inhibitor-induced prostaglandin synthesis. Ticlopidine is a potent antiplatelet agent without interaction with prostaglandin synthesis. METHODS AND RESULTS: The objective of this study was to compare the influence of a coadministration of ticlopidine or aspirin on the hemodynamic effects of an ACE inhibitor (enalapril) in patients with chronic heart failure. Twenty patients with severe heart failure were enrolled in a double-blind comparative trial and allocated to ticlopidine (500 mg daily, 12 patients) or aspirin (325 mg daily, 8 patients). Hemodynamic evaluation was performed after 7 days of treatment, every hour for 4 hours after an oral administration of 10 mg of enalapril. Significant reductions in systemic vascular resistance were observed in the ticlopidine group, in contrast to no significant decrease in the aspirin group. A significant (P=0.03) time-by-treatment interaction indicated significant aspirin-enalapril drug interaction. Total pulmonary resistance decreased significantly in both groups, with no difference between patients assigned to aspirin or ticlopidine. CONCLUSIONS: Enalapril reduced systemic vascular resistance more effectively when given in combination with ticlopidine than with aspirin. In contrast, the reduction in total pulmonary resistance is similar when enalapril is administered in combination with aspirin or ticlopidine. Negative aspirin-enalapril interaction on prostaglandin synthesis presumably alters vasodilatation in systemic vessels, whereas prostaglandin-independent actions of ACE inhibition such as pulmonary arterial vasodilatation are maintained.

One-week and six-month angiographic controls of stent implantation after occlusive and nonocclusive dissection during primary balloon angioplasty for acute myocardial infarction.

We prospectively assessed in 124 consecutive patients by means of 1-week and 6-month follow-up angiograms the rate of reocclusion and restenosis of coronary stenting with Palmaz-Schatz stents after occlusive and nonocclusive dissection during primary balloon angioplasty for acute myocardial infarction (AMI). Patients were further evaluated clinically at 1 year. Stenting was performed on large (>3.2 mm) coronary arteries for suboptimal results (47%), occlusive (8%), or nonocclusive dissections (45%) after balloon angioplasty. Stents were delivered using the bare stent technique and high pressure inflations (>12 atm). All patients received ticlopidine 250 mg (500 mg if weight was >80 kg) and aspirin 100 mg for 1 month. No patient received warfarin. At 1 week, 6 patients died of cardiogenic shock and 2 of right ventricular infarction. One subacute occlusion occurred at day 14. At 6 months, in 95 patients, the angiographic restenosis rate (>50% diameter stenosis) was 19%. One-year clinical follow-up, available in 55 patients, indicated cardiac death in 5, and repeat revascularization in 3. Thus, coronary stenting on large (>3.2 mm) coronary arteries after occlusive and nonocclusive dissection during primary balloon angioplasty for AMI using bare Palmaz-Schatz stents, high pressures, ticlopidine, and aspirin is safe. Our reocclusion and restenosis rates are similar to those of trials on elective stenting in stable patients.

Changes in immediate outcome of percutaneous transluminal coronary angioplasty in multivessel coronary artery disease in 1990 to 1991 versus 1994 to 1995.

Coronary angioplasty has undergone major technical changes since the period of inclusion in the randomized trials, comparing it with surgery, particularly with the increased use of coronary stents. This study shows improved in-hospital outcome in terms of primary success and complication rates in patients treated with coronary angioplasty for multivessel disease from 1994 to 1995, compared with the 1990 to 1991 period.

[Prescription of heparin in the acute phase of myocardial infarction: expected and observed benefits...]. / Prescription d'héparine au cours de l'infarctus du myocarde en phase aiguë: bénéfices attendus, bénéfices constatés...

Before the advent of thrombolysis, heparin was widely used in the acute phase of myocardial infarction. Its prescription was based on trials, often of criticable methodology, some of which showed a reduction in hospital mortality and others a reduction in the incidence of reinfarction, left ventricular thrombi or venous thromboembolism. A better understanding of physiopathology and the development of emergency methods of myocardial reperfusion (pharmacological or mechanical) showed that the real objective of management of acute myocardial infarction should be reopening of the occluded artery and the maintenance of its patency. Reocclusion which occurs in 20% of cases in associated with increased hospital morbidity and mortality. Heparin, which limits the paradoxial increase of thrombin after thrombolysis significantly decreases this risk. Two reference trials on the benefits of heparin in association with thrombolysis, GISSI-2 and ISIS-3, demonstrated a significant reduction in the 7 day mortality but no significant reduction in the 35 day mortality. The poor quality of the anticoagulation protocol, especially in patients receiving rtPA, explains these disappointing results. Thus, it has now been clearly established that heparin, even though it increases the number of bleeding complications should be associated early and at an appropriate dosage with all thrombolytic regimes or mechanical reperfusion methods used during acute myocardial infarction. Apart from the embolic complications or ventricular thrombosis, this anticoagulation only seems to be justified during the first 48 hours.

Effect of late percutaneous angioplastic recanalization of total coronary artery occlusion on left ventricular remodeling, ejection fraction, and regional wall motion.

The clinical benefit of late recanalization of complete coronary occlusion is debated. Left ventricular (LV) function and volumes are major prognostic determinants in patients with coronary artery disease. We sought to assess comprehensively the evolution of global and regional LV function and LV volumes after percutaneous recanalization of chronic complete coronary artery occlusions. A consecutive series of 55 patients who underwent successful percutaneous recanalization of a chronic (> or = 10 days), total (Thrombolysis in Myocardial Infarction trial flow grade 0) occlusion of the left anterior descending or dominant right coronary arteries, and in whom a complete angiographic evaluation was available before angioplasty and at follow-up was studied. At follow-up, 38 patients had a patent artery (group 1) and 17 had a reocclusion (group 2). Baseline parameters were similar in the 2 groups. In group 1, LV ejection fraction increased from 55 +/- 14% to 62 +/- 13% (p <0.001), with an increase in fractional shortening in the occluded artery territory (0.43 +/- 0.30 to 0.71 +/- 0.34, p <0.001), while LV end-diastolic volume remained unchanged. In group 2, ejection fraction and regional wall motion were unchanged, while LV end-diastolic volume index increased (86 +/- 22 ml/m2 to 99 +/- 34 ml/m2, p <0.02). The evolution in LV global and regional function was similar in patients with or without previous myocardial infarction; however, prevention of LV remodeling was observed only in patients with previous infarction. Maintained potency after successful recanalization of totally occluded coronary arteries improves global and regional LV function and, in patients with previous myocardial infarction, avoids LV remodeling.

[Physiopathology of unstable angina]. / Physiopathologie de l'angor instable.

The majority of cases of unstable angina and myocardial infarction have a common origin: rupture of an atheromatous plaque complicated by intracoronary thrombosis. The nature of these "high risk" plaques is now well known: they are excentric, moderately severe lesions, the voluminous lipid centres of which are covered only by a thin unstable fibrous layer. The triggering factor of the rupture of an unstable plaque may be an increase in wall stress (spastic vasoconstriction, rise in blood pressure), and/or an inflammatory or haemorrhagic phenomenon within the plaque itself. Once the plaque has ruptured, the outcome to unstable angina or myocardial infarction is determined by two factors: the size and rapidity of constitution of the thrombus and the quality of the collateral circulation.