A randomized study comparing isotope and echocardiography stress testing in the screening of silent myocardial ischaemia in type 2 diabetic patients.

AIMS: This study aimed to compare the positive predictive value (PPV) of stress myocardial scintigraphy (SPECT) and of dobutamine echocardiography (DE) in the diagnosis of significant coronary artery stenosis (CAD) in asymptomatic type 2 diabetic patients, and to assess long-term clinical outcomes according to silent myocardial ischaemia (SMI) screening. METHODS: A total of 204 asymptomatic type 2 diabetic patients at high cardiovascular (CV) risk were prospectively randomized to undergo either SPECT (n=104) or DE (n=100). Coronary angiography was proposed in cases of SMI, with revascularization of suitable lesions. Intensive treatment of CV risk factors was prescribed for all patients. Death and myocardial infarction (MI) were recorded during the 3-year follow-up. RESULTS: Clinical characteristics were similar in the two testing groups. The prevalence of SMI and significant CAD were 13% and 4%, respectively, in the SPECT group vs 11% and 5%, respectively, in the DE group (not significant [NS]). The PPV for the detection of significant CAD was 29% for SPECT and 45% for DE (NS). Seven patients (3%) underwent initial revascularization. The 3-year rate of CV death and MI was 2.5%, and similar in both groups. CONCLUSION: Rates of SMI and significant CAD in asymptomatic high-risk type 2 diabetic patients receiving intensive care of risk factors are low, and SPECT and DE are similar in the detection of SMI and CAD. Coronary revascularization and intensive CV risk-factor therapy are associated with a low rate of adverse CV events at 3 years, whichever stress test was used.

A hereditary moyamoya syndrome with multisystemic manifestations.

OBJECTIVE: We report a detailed description of a family affected by a hereditary multisystem disorder associated with moyamoya syndrome. METHODS: In this family case report, we evaluated 9 members of the same family originating from Algeria. Investigations included neuroimaging, cardiologic and ophthalmologic evaluation, hormonal testing, hemoglobin electrophoresis, chromosomal karyotyping, muscle biopsy for morphology, immunohistochemistry and enzyme assays, mtDNA mutation screening, and haplotype analysis of 2 loci previously linked to moyamoya, on chromosomes 10 (ACTA2) and 17. RESULTS: Five males related through a maternal lineage were affected, suggesting an X-linked inheritance. Four of them had symptomatic moyamoya syndrome with an onset of acute neurologic manifestations between 4 and 32 years. Hypergonadotropic hypogonadism, azoospermia, short stature of postnatal onset (-2 to -4 SD in adulthood), premature graying of hair, and dysmorphism were present in all patients. The other features of the disease included early cataract in 4, dilated cardiomyopathy in 3, and partial growth hormone deficiency in 2 members. Muscle biopsy data did not reveal signs of a mitochondrial disorder. All conditions known to be associated with moyamoya syndrome such as Down syndrome, neurofibromatosis, and sickle cell disease were excluded. We also excluded linkage to the 2 loci previously reported to be involved in autosomal dominant syndromic and nonsyndromic moyamoya. Carrier females had normal phenotype and clinical history. CONCLUSIONS: These data strongly suggest that this family is affected by a hereditary moyamoya multisystem disorder with X-linked recessive pattern of inheritance.

[Multidetector computed tomography coronarography: from studies to everyday life]. / Le scanner coronaire : des études à la pratique courante.

INTRODUCTION: Multidetector computed tomography coronarography is a promising tool, offering a non-invasive anatomic evaluation of coronary arteries. The great majority of studies conducted upon it are single-center studies, and have reported results based upon a highly selected patient population. Our aim was to determine its diagnostic accuracy among an unselected population in multicenter studies. METHODS: Fifty-two patients were included in a non-randomised, retrospective study. Patients underwent multidetector computed tomography coronarography (16, 40 and 64 slices), in ten different centers (community hospitals or private centres), for clinical suspicion of coronary stenoses. The diagnostic accuracy for detecting significant coronary stenoses (> or =50%) was determined in comparison with conventional coronarography. RESULTS: The sensitivity, specificity, positive and negative predictive values and diagnostic accuracy were 91.4%, 17.7%, 69.6%, 50.0%, and 67.3%, respectively, in a patient-based analysis, and 55.3%, 85.6%, 30.3%, 94.4% and 82.5% in a segment-based analysis. CONCLUSION: The results of this study indicate that routine implementation of multidetector computed tomography coronarography is limited by a high false-positive rate, when performed among an unselected population of patients with a high pretest probability of having coronary stenoses, in centres with variable expertises. Its place within the range of diagnostic tools has yet to be determined by large multicenter studies, before being subject to precise recommendations framing its routine clinical application.

Characteristics and prognosis of patients with angiographic stent thrombosis: comparison between drug-eluting and bare-metal stents.

INTRODUCTION: Conflicting data exist on the risk of stent thrombosis with drug-eluting stents (DES) versus bare-metal stents (BMS). Little is known about the potential different characteristics and outcomes of DES versus BMS thrombosis. OBJECTIVE: To compare the characteristics, timing and outcomes of patients with angiographic stent thrombosis according to type of stent implanted. METHODS: The population comprised consecutive patients who underwent BMS or DES implantation (January 2003-April 2007) at Pitié-Salpêtrière Hospital. Data from patients with and without a stent thrombosis were compared to identify predictors of thrombosis. Timing of thrombosis (acute,<24 hours; subacute,<30 days; late,>30 days; very late,>1 year), clinical, angiographic and procedural characteristics, and outcomes were compared between patients with a BMS or DES thrombosis. RESULTS: A total of 3579 patients received a BMS (2815 lesions, 2318 patients) or a DES (1536 lesions, 1261 patients). Documented angiographic stent thrombosis occurred in 52 (1.4%) patients, 16 (1.3%) with a DES and 36 (1.6%) with a BMS. Rates of acute (0.1% versus 0.2%), subacute (1% versus 0.7%), late (both 0.2%) and very late (both 0.2%) thrombosis were similar in patients with BMS and DES thrombosis. Factors predictive of stent thrombosis were similar, including left ventricular failure (P<0.0001), initial percutaneous coronary intervention (PCI) for acute myocardial infarction (P<0.0001), multivessel PCI (P<0.0001), and balloon dilatation before stenting (P<0.04). Eleven (21%) cases of BMS (n=8, 22%) or DES (n=3, 19%) thrombosis arose soon after stopping antiplatelet therapy. Thirteen of 52 (25%) patients died a few hours after the event. Twenty-seven (52%) major adverse cardiac events occurred at 18 months, 7 in patients with a DES and 20 in those with a BMS (44% versus 55%, P=NS). These included 16 deaths (31%), 7 repeat PCIs and 4 myocardial infarctions. There were no independent predictive factors of death after stent thrombosis. CONCLUSIONS: BMS and DES thrombosis are similar in terms of timing of thrombosis, characteristics and outcomes, and share the same risk of late thrombosis after interruption of antiplatelet therapy.

Medium-term survival after primary angioplasty for myocardial infarction complicated by cardiogenic shock after the age of 75 years.

AIMS OF THE STUDY: To assess mortality in people > or =75 years of age 6 months after myocardial infarction complicated by cardiogenic shock and treated by angioplasty with complete revascularisation and optimal anti-thrombotic treatment; to compare results to those of younger patients with or without shock and to analyse predictive factors for death. MATERIALS AND METHODS: The study is based on 1011 consecutive patients with myocardial infarction admitted for primary angioplasty, subdivided into four groups by age and the presence or absence of cardiogenic shock: group 1 (<75 years of age without shock, n=733), group 2 (<75 years of age with shock, n=49), group 3 (> or =75 years of age without shock, n=208) and group 4 (> or =75 years of age with shock, n=20). These four patient groups were compared for mortality rates and predictive factors for in-hospital and 6 month mortality. RESULTS: In-hospital mortality in groups 1 to 4 was 1.7%, 30.6%, 9.1%, and 70% (p<0.0001) respectively and 6-month mortality was 3.1%, 40%, 16% and 78% (P<0.0001). By univariate analysis renal failure was a predictive factor for death at 6 months in patients without cardiogenic shock (groups 1 and 3), and left ventricular function in patients in group 2. No predictive factors were found in group 4 patients. The independent predictive factors for death at 6 months were: age >75 years of age (P<0.0003), cardiogenic shock (P<0.0001), triple vessel lesions (P<0.01) and creatinine clearance (P=0.004). CONCLUSION: Mortality after angioplasty remains high in people > or =75 years with cardiogenic shock despite all the advances in the management of myocardial infarction. These disappointing results should encourage us to assess the role of surgical revascularisation and circulatory assistance.

Relief influence on the spatial distribution of the Atlantic Forest cover on the Ibiúna Plateau, SP.

Several studies suggest that, on a large scale, relief conditions influence the Atlantic Forest cover. The aim of this work was to explore these relationships on a local scale, in Caucaia do Alto, on the Ibiúna Plateau. Within an area of about 78 km(2), the distribution of forest cover, divided into two successional stages, was associated with relief attribute data (slope, slope orientation and altitude). The mapping of the vegetation was based on the interpretation of stereoscopic pairs of aerial photographs, from April 2000, on a scale of 1:10,000, while the relief attributes were obtained by geoprocessing from digitalized topographic maps on a scale of 1:10,000. Statistical analyses, based on qui-square tests, revealed that there was a more extensive forest cover, irrespective of the successional stage, in steeper areas (>10 degrees) located at higher altitudes (>923 m), but no influence of the slope orientation. There was no sign of direct influence of relief on the forest cover through environmental gradients that might have contributed to the forest regeneration. Likewise, there was no evidence that these results could have been influenced by the distance from roads or urban areas or with respect to permanent preservation areas. Relief seems to influence the forest cover indirectly, since agricultural land use is preferably made in flatter and lower areas. These results suggest a general distribution pattern of the forest remnants, independent of the scale of study, on which relief indirectly has a strong influence, since it determines human occupation.

Relief influence on the spatial distribution of the Atlantic Forest cover on the Ibiúna Plateau, SP

Several studies suggest that, on a large scale, relief conditions influence the Atlantic Forest cover. The aim of this work was to explore these relationships on a local scale, in Caucaia do Alto, on the Ibiúna Plateau. Within an area of about 78 km², the distribution of forest cover, divided into two successional stages, was associated with relief attribute data (slope, slope orientation and altitude). The mapping of the vegetation was based on the interpretation of stereoscopic pairs of aerial photographs, from April 2000, on a scale of 1:10,000, while the relief attributes were obtained by geoprocessing from digitalized topographic maps on a scale of 1:10,000. Statistical analyses, based on qui-square tests, revealed that there was a more extensive forest cover, irrespective of the successional stage, in steeper areas (>10 degrees) located at higher altitudes (>923 m), but no influence of the slope orientation. There was no sign of direct influence of relief on the forest cover through environmental gradients that might have contributed to the forest regeneration. Likewise, there was no evidence that these results could have been influenced by the distance from roads or urban areas or with respect to permanent preservation areas. Relief seems to influence the forest cover indirectly, since agricultural land use is preferably made in flatter and lower areas. These results suggest a general distribution pattern of the forest remnants, independent of the scale of study, on which relief indirectly has a strong influence, since it determines human occupation.

Vários estudos sugerem que as condições do relevo influenciam, em larga escala, a cobertura da Mata Atlântica. Este trabalho teve por objetivo explorar estas relações em escala local, na região do Planalto de Ibiúna, denominada de Caucaia do Alto. Numa área de cerca de 78 km², procurou-se associar a cobertura florestal, dividida em dois estádios sucessionais, com atributos do relevo (declividade, orientação de vertente e altitude). O mapeamento da vegetação foi feito a partir da interpretação de pares estereoscópicos de fotografias aéreas de abril de 2000, na escala 1:10.000, enquanto os atributos do relevo foram gerados por geoprocessamento a partir de cartas topográficas digitalizadas, em escala 1:10.000. As análises estatísticas, baseadas em testes de qui-quadrado, revelam que há maior cobertura florestal, independentemente do estádio sucessional, em áreas mais íngremes (>10 graus) e situadas em altitudes mais elevadas (>923 m), porém não há influência da orientação de vertente. Não há indícios de influência direta do relevo sobre a cobertura florestal, através de gradientes ambientais que poderiam agir na regeneração florestal. Também não foram obtidas evidências de que estes resultados possam ser influenciados pelo distanciamento a estradas ou centros urbanos, ou ainda pelo respeito às áreas de preservação permanente. O relevo parece determinar o recobrimento florestal, principalmente por condicionar o uso agrícola dos solos, que se dá preferencialmente em áreas mais planas e baixas. Estes resultados sugerem um padrão geral de influência do relevo sobre a distribuição dos remanescentes florestais, independentemente da escala de estudo, onde o relevo atua indiretamente ao condicionar a ocupação humana.

[The value of active stents for coronary angioplasty in patients with chronic renal failure]. / Intérêt du stent actif dans l'angioplastie coronaire chez l'insuffisant rénal chronique.

UNLABELLED: The risk of intra-stent restenosis has diminished considerably with the advent of endoprostheses which actively release sirolimus or paclitaxel. Patients with chronic renal failure constitute a high cardiovascular risk population, in whom the incidence of coronary heart disease is particularly high, representing one of the principal causes of death. The aim of this study, which included 152 patients, was to quantify the value of active stents for coronary angioplasty in patients with chronic renal failure. Thirty eight patients with chronic renal failure who underwent angioplasty with active stents were matched for age, sex and the presence of diabetes with 3 other groups of patients: one group with active stents but without renal failure, one group with inactive stents and no renal failure, and one group with inactive stents and chronic renal failure. The average follow up was 16 +/- 5 months. The acute stent thrombosis rate (2%) was not elevated in cases of renal failure nor after active stent implantation. Chronic renal failure significantly increased the mortality rate 16 months after angioplasty, whichever type of stent was used: 8 versus 2% deaths in patients with an inactive stent (p = 0.001). In renal failure, the risk of death was lower with an active stent (8 vs 26% with an inactive stent, p<0.05). Similarly, there was a non-significant trend towards a lower risk of death and/or infarction in renal failure after active stents (8 vs 21% with an inactive stent, NS). CONCLUSIONS: In this study, coronary angioplasty with an active stent in patients with chronic renal failure was associated with a lower mortality rate compared with inactive stents, with no increase in the risk of acute thrombosis.

Stress myocardial scintigraphy and dobutamine echocardiography in the detection of coronary disease in asymptomatic patients with type 2 diabetes.

OBJECTIVE: The aims of this prospective study were: (1) to compare stress thallium-201 single photon emission computed tomography (SPECT) and dobutamine echocardiography (DE) in the detection of silent myocardial ischemia (SMI) in asymptomatic high risk diabetic patients; (2) to analyse long-term outcome after intensive care of SMI in these patients. METHODS: SPECT was performed in 100 high risk diabetic patients and DE in the first 75 patients. Coronary angiography was realized in patients with SMI, with revascularization for suitable lesions. Intensive treatment of atherosclerosis risk factors was performed in all patients. Patients were followed 2 +/- 0.5 years for the subsequent occurrence of cardiac death, myocardial infarction and revascularization. RESULTS: SMI was detected by SPECT in 62% and by DE in 10% of the patients (p < 0.0001), whereas significant coronary stenosis at angiography was detected by SPECT in 26% and by DE in 5% of the patients (p < 0.02). Independent predictive factors of significant coronary stenosis were male gender (p < 0.03) and peripheral arterial disease (p < 0.007). Nonfatal acute coronary syndrome occurred during follow-up in 2 patients (2%). Subsequent revascularization procedure was needed in 9 patients. Baseline patients' characteristics, as well as SMI, were not predictive of cardiac event during follow up. CONCLUSION: SPECT seems more accurate than DE to detect significant coronary stenosis in high risk asymptomatic diabetic patients. In this population, aggressive treatment of SMI with systematic revascularization combined with intensive care of risk factors is associated with a favorable long-term prognosis, similar in diabetic patients with and without initial SMI.

Cumulative adverse effects of diabetes mellitus and hypertension on coronary flow velocity reserve.

BACKGROUND: this study aimed to assess the hypothesis that essential hypertension (EH) may increase coronary microcirculation dysfunction in patients with type 2 diabetes mellitus (DM). Microvascular dysfunction has been reported in patients with DM or EH. Discordant results have been reported on cumulative adverse effects of the simultaneous presence of DM and EH on coronary flow velocity reserve (CFR). METHODS: CFR were compared in 13 hypertensive diabetics (group 1), 12 normotensive diabetics (group 2), 11 hypertensive non diabetics (group 3) and 29 normotensive non diabetic patients (group 4). CFR was calculated using an intracoronary Doppler-tipped flow wire. RESULTS: CFR was significantly lower in patients with both DM and EH (2.2 +/- 0.4 in group 1 vs 2.8 +/- 0.5, 2.8 +/- 0.6 and 2.9 +/- 0.7 in groups 2, 3 and 4 respectively, p<0.01). The presence of hypertension reduced CFR in diabetic patients with angiographically abnormal but unobstructed coronary arteries (2.1 +/- 0.3 in hypertensive vs 3.1 +/- 0.2 in normotensive diabetic patients, p<0.02). No cumulative adverse effect was observed in diabetics with angiographically normal coronary arteries (2.3 +/- 0.6 in hypertensive vs 2.6 +/- 0.5 in normotensive diabetic patients, NS). Multivariate analysis revealed that combination of DM and EH (p<0.007) was independently related to CFR. CONCLUSIONS: the presence of hypertension appears to worsen coronary microangiopathy in diabetic patients with unobstructed coronary artery disease. The cumulative effect of EH and DM on CFR impairment has consequences for decision-making during coronary angioplasty and could identify patients at risk for cardiomyopathy.

Impact of prior use or recent withdrawal of oral antiplatelet agents on acute coronary syndromes.

BACKGROUND: Oral antiplatelet agents (OAAs) can prevent further vascular events in cardiovascular disease. How prior use or recent discontinuation of OAA affects clinical presentation of acute coronary syndromes (ACS) and clinical outcomes (death, myocardial infarction [MI]) is unclear. METHODS AND RESULTS: We studied and followed up for up to 30 days a cohort of 1358 consecutive patients admitted for a suspected ACS; of these, 930 were nonusers, 355 were prior users of OAA, and 73 had recently withdrawn OAA. Nonusers were at lower risk, more frequently presented with ST-elevation MI on admission, and more frequently had Q-wave MI at discharge than prior users (36.6% versus 17.5%, P<0.001; and 47.8% versus 28.2%, P<0.001, respectively). However, there was no difference regarding the incidence of death or MI at 30 days between nonusers and prior users (10.3% versus 12.4%, P=NS). In addition, prior users experienced more major bleeds within 30 days compared with nonusers (3.4% versus 1.4%, respectively; P=0.04). Recent withdrawers were admitted on average 11.9+/-0.8 days after OAA withdrawal. Interruption was primarily a physician decision for scheduled surgery (n=47 of 73). Despite a similar cardiovascular risk profile, recent withdrawers had higher 30-day rates of death or MI (21.9% versus 12.4%, P=0.04) and bleedings (13.7% versus 5.9%, P=0.03) than prior users. After multivariate analysis, OAA withdrawal was found to be an independent predictor of both mortality and bleedings at 30 days. CONCLUSIONS: Among ACS patients, prior users represent a higher-risk population and present more frequently with non-ST-elevation ACS than nonusers. Although patients with a recent interruption of OAA resemble those chronically treated by OAA, they display worse clinical outcomes.

[Thrombosis caused by active rapamycin stents]. / Thrombose de stents actifs à la rapamycine.

We report the case history of a patient aged 68 years presenting with a recurrence of anterior myocardial infarction complicated by cardiogenic shock with a thrombosis of an active rapamycin stent 77 days following the angioplasty procedure. This was provoked by stopping platelet anti-aggregant treatment, a diabetic background and in the context of scheduled surgery for cancer recurrence. Recent data in the literature combined with our observations prompt the continuation of anti-aggregant bi therapy for at least 9 months after endoprosthesis insertion even if an active stent is used. In the case where surgery is envisaged, it is necessary to wait at least 6 months after the rapamycin stent revascularisation procedure. If an extra-cardiac procedure is envisaged during the angioplasty, it would be preferable to not use an active stent.

[Clopidogrel and thrombopenia. A case report]. / Clopidogrel et thrombopénie. A propos d'un cas.

We report our experience with a case of isolated profound thrombocytopenia after clopidogrel (thienopyridine) administration. No adverse event such as bleeding or thrombotic event had occurred, although clopidogrel has been discontinued two weeks after the coronary artery stenting. Despite the safety of clopidogrel, this case demonstrates that clopidogrel can be associated not only with thrombotic thrombocytopenic purpura but also with isolated thrombocytopenia.

Myocardial viability, coronary flow reserve, and in-hospital predictors of late recovery of contractility following successful primary stenting for acute myocardial infarction.

OBJECTIVE: To assess the relation between myocardial viability, coronary flow reserve, and recovery of myocardial contractility after stenting for acute myocardial infarction. DESIGN: Consecutive sample prospective study. SETTING: University hospital. PATIENTS: 41 patients with single vessel disease and successful primary stenting for a first acute myocardial infarction. INTERVENTIONS: (201)Tl single photon emission computed tomography, contrast ventriculography, and intracoronary Doppler performed 7 (1) days after primary stenting. MAIN OUTCOME MEASURES: Regional contractility recovery assessed by contrast ventriculography at 6 (1) months' follow up. RESULTS: On univariate analysis, contractility recovery was correlated to prereperfusion anterograde and collateral flow grades (r = 0.41, p = 0.03 and r = 0.55, p = 0.0004), viability index (r = 0.55, p = 0.04), peak creatine kinase concentrations (r = -0.55, p = 0.0005), left ventricular ejection fraction (r = 0.45, p = 0.005), end diastolic pressure (r = -0.62, p < 0.0001), end systolic volume index (r = -0.47, p = 0.01), and the extent of hypokinetic area (r = -0.48, p = 0.003), but not the coronary flow reserve. On multivariate analysis, independent predictors of late contractility recovery were prereperfusion anterograde and collateral flow grades and viability index. Relative coronary flow reserve, reflecting the culprit vessel's microvascular function, was correlated only to the extent of the infarct risk area (r = -0.45, p = 0.003). CONCLUSIONS: Independent predictors of contractility recovery between the seventh day and the sixth month after successful stenting for acute myocardial infarction are prereperfusion anterograde and collateral flows and myocardial viability. The culprit vessel's microvascular dysfunction is independent of myocardial viability and contractility and correlated to the extent of "jeopardised microvasculature".

[Absence of nephro-protective effect of acetylcysteine in patients with chronic renal failure investigated by coronary angiography]. / Absence d'effet néphroprotecteur de l'acetylcystéine chez les patients avec insuffisance rénale chronique explorés par coronarographie.

Recent studies have suggested that an oral dose of acetylcysteine could play a prophylactic role in the prevention of nephrotoxicity from iodine contrast media in patients affected by chronic renal failure. Between June 2001 and September 2002 we selected 120 patients with a basal plasma creatinine level greater than 1.36 mg/dl investigated by coronary angiography. The treatment group included 60 patients who received 600 mg of acetylcysteine in the morning and evening before the day of the examination together with intravenous saline hydration. The control group patients received hydration alone. The clinical characteristics of the groups were comparable as well as the basal plasma creatinine level: 2.01+/-1.1 mg/dl in the acetylcysteine group and 1.81+/-0.69 in the control group. The plasma creatinine level was measured 24 and 48 hours after coronary angiography. The respective changes in plasma creatinine level at 24 and 48 hours were 0.12+/-0.29 and 0.02+/-0.29 mg/dl in the acetylcysteine group and 0.06+/-0.29 and 0.07+/-0.43 mg/dl in the control group (NS). Acute renal failure caused by the contrast medium, defined by an increase of 25% in the plasma creatinine level compared to the basal value, occurred in 3 patients from the acetylcysteine group and 2 patients from the control group. The only predictive factor for acute renal failure was the quantity of contrast medium (316+/-141 vs 173+/-115 ml, p<0.05). In conclusion, acute renal failure caused by contrast medium is rare in sufficiently hydrated patients with moderate chronic renal failure when a low dose of contrast medium is used. Our study does not confirm a prophylactic effect of acetylcysteine in the prevention of nephrotoxicity from contrast media following coronary angiography in patients with moderate chronic renal failure.

[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.

[Mediastinal tumor revealed by myocardial infarction]. / Tumeur médiastinale révélée par un infarctus du myocarde.

We report the case of a patient with a past history of coronary atherosclerosis treated with primary angioplasty 5 hours following an inferior myocardial infarction. Echocardiography performed during the procedure revealed a mediastinal tumour invading the tricuspid, responsible for the occlusion of the right coronary. Infarction due to tumour compression is a rare presentation of mediastinal tumour. Diagnosis relies on echocardiographic, CT or magnetic resonance imaging. The prognosis is linked to the tumour pathology.

[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.