[Secondary prevention of cardiovascular diseases : targeting all the cardiovascular risk factors]. / Prévention secondaire des maladies cardiovasculaires : cibler l'ensemble des facteurs de risque.

This article focuses on the secondary prevention of cardiovascular (CV) diseases, namely the prevention of recurrence in subjects with a personal history of CV event, and the prevention of a first event in patients identified as at very high risk. For all these patients at very high risk, treatment is primarily based on the application of hygienic and dietary measures, including increasing the volume of physical activity, modifying the diet, and obtaining, if necessary, weight loss, as well as stopping smoking. This strategy has proven its benefits in terms of reducing morbidity and mortality. In addition, these patients must receive pharmacological treatment, whose the additional benefits are proven. The article details the pharmacological classes that are currently recommended, as well as the optimal management of CV risk factors and the therapeutic targets to be achieved.

Cet article s'intéresse à la prévention secondaire des maladies cardio-vasculaires (CV), c'est-à-dire la prévention de la récidive chez les sujets ayant une histoire personnelle d'événement CV, et la prévention d'un premier événement chez les patients identifiés comme à très haut risque. Pour tous ces patients à très haut risque, la prise en charge est, avant tout, basée sur l'application de mesures hygiéno-diététiques, incluant l'augmentation du volume d'activité physique, la modification du régime alimentaire et l'obtention si nécessaire d'une perte pondérale, ainsi que l'arrêt du tabac. Cette stratégie a prouvé ses bénéfices en termes de réduction de la morbidité et de la mortalité. En outre, ces patients doivent recevoir un traitement pharmacologique, dont les bénéfices additionnels sont prouvés. L'article détaille les classes pharmacologiques recommandées actuellement, ainsi que la prise en charge optimale des facteurs de risque CV et les cibles thérapeutiques à atteindre.

Cardiac Damage and Conduction Disorders after Transcatheter Aortic Valve Implantation.

Recently, a staging system using 4 grades has been proposed to quantify the extent of cardiac damage associated with aortic stenosis (AS), namely AS-related cardiac damage staging (ASCDS). ASCDS is independently associated with all-cause mortality and important clinical outcomes. To evaluate whether it might be associated with the occurrence of conduction system disorders after TAVI, a total of 119 symptomatic patients with severe AS who underwent a TAVI were categorized according to ASCDS: group 1 (13.5%): no or LV damage; group 2 (58.8%): left atrial/mitral valve damage, atrial fibrillation (AF); group 3 (27.7%): low-flow state, pulmonary vasculature/tricuspid valve/RV damage. After TAVI, 34% of patients exhibited LBBB and 10% high-degree atrioventricular block (HD-AVB). No patient in group 1 developed HD-AVB whereas new LBBB was frequent in groups 2 and 3. Twenty-one patients presented with paroxysmal AF with a higher rate for each group increment (group 1: n = 0, 0%; group 2: n = 11, 15.7%; group 3: n = 10, 30.3%) (p = 0.012). Patients in group 3 had the higher rate of permanent pacemaker implantation (PPMI) (group 1: n = 1, 6.3%; group 2: n = 7, 10%; group 3: n = 9, 27.3%) (p = 0.012). In conclusion, ASCDS might help identify patients at higher risk of conduction disorders and PPMI requirement after TAVI.

[Aortic stenosis : new developments in management]. / Sténose aortique : nouveautés thérapeutiques et diagnostiques.

Aortic stenosis (AS) is the most common valve disease in our countries; most often of degenerative origin, its prevalence is constantly increasing due to the aging of the population. Its development is a continuum ranging from aortic sclerosis to severe aortic stenosis, the diagnosis of which is essentially based on transthoracic echocardiography, which will allow classification into subcategories. Even if today no treatment makes it possible to prevent the progression of the disease, the management has clearly evolved with an increasingly important place for new approaches to valve replacement by the percutaneous route, and an indication of management at an increasingly early stage.

La sténose aortique (SA) est la valvulopathie la plus fréquente dans les pays occidentaux, le plus souvent d'origine dégénérative, et sa prévalence augmente constamment étant donné le vieillissement de la population. Son développement est un continuum allant de la sclérose aortique vers la sténose aortique serrée, dont le diagnostic repose essentiellement sur l'échocardiographie trans-thoracique qui permettra une classification en sous-catégories. Même si aujourd'hui aucun traitement ne permet d'empêcher la progression de la maladie, sa prise en charge a nettement évolué avec une place de plus en plus importante pour les techniques de remplacement valvulaire par voie percutanée, et une indication de prise en charge qui sera posée de façon de plus en plus précoce.

[Cardio-oncology and cardio-obstetrics : crucial role of a multidisciplinary approach]. / Cardio-oncologie et cardio-obstétrique : importance d'une approche multidisciplinaire.

In this clinical case, we describe the cardio-oncological history and the complexity of the management of a patient presenting a breast cancer diasgnosed during pregnancy followed by a postpartum cardiomyopathy. A multidisciplinary approach is mandatory.

Dans ce cas clinique, nous décrivons l'histoire cardio-oncologique et la complexité de prise en charge d'une patiente présentant un cancer mammaire découvert lors d'une grossesse, puis, une cardiomyopathie du post-partum. Une approche multidisciplinaire s'avère indispensable.

A new integrative approach combining right heart catheterization and echocardiography to stage aortic stenosis-related cardiac damage.

Introduction: Although staging of the extent of aortic stenosis (AS)-related cardiac damages is usually performed via echocardiography, this technique has considerable limitations in assessing pulmonary artery and right chamber pressures. The present hypothesis-generating study sought to explore the efficacy of a staging system of cardiac damage based on echocardiographic and invasive [right heart catheterization (RHC)] hemodynamic parameters in patients undergoing transcatheter aortic valve implantation (TAVI). Methods: We studied 90 symptomatic patients with severe AS in whom echocardiographic and invasive evaluation by RHC was obtained prior to TAVI. Cardiac damage stages were defined as follows: no cardiac damage (stage 0), left ventricular (LV) damage (stage 1), left atrial or mitral valve damage (stage 2), pulmonary vasculature or tricuspid valve damage (stage 3), and right ventricular (RV) dysfunction or low-flow state (stage 4). With the integrative approach using RHC, pulmonary hypertension (PH) was defined as an mPAP ≥25 mmHg and the low-flow state corresponded to a cardiac index of <1.8 L/min/m2 and a right atrial pressure of >10 mmHg. Results: During follow-up (median: 2.9 years), 43 patients (47.8%) died. The integrative cardiac damage staging was associated with a significant increase in all-cause and cardiovascular mortality per each increase of cardiac damage stage, whereas the outcome was similar according to the echocardiographic staging. Conclusions: A staging system of cardiac lesion based on echocardiographic and invasive hemodynamic parameters in patients with severe AS undergoing TAVI predicts mortality. Patients with pre-existing PH, ≥ moderate tricuspid regurgitation and/or RV dysfunction, and a low-flow state had a markedly increased risk of death. Further larger studies are needed to validate our findings.

[Advances in pulmonary hypertension diagnosis and risk stratification]. / Nouveautés dans le diagnostic et la stratification du risque de l'hypertension pulmonaire.

Pulmonary hypertension (PH) is a common clinical condition linked to chronic cardiopulmonary illnesses. It must be distinguished from pulmonary arterial hypertension (PAH), a rare disease characterized by a specific involvement of the pulmonary arterial bed. An early diagnosis and accurate classification by a multidisciplinary team are necessary for a multimodal and individualized therapy approach. This article aims to provide a summary of the most recent ESC/ERS recommendations published in 2022.

L'hypertension pulmonaire (HTP) est une entité clinique fréquemment retrouvée chez les patients atteints d'affections cardio-pulmonaires chroniques. Elle est à différentier de l'hypertension artérielle pulmonaire (HTAP) qui est, quant à elle, une maladie rare caractérisée par une atteinte spécifique du lit artériel pulmonaire. Une identification précoce et une classification correcte, en équipe pluridisciplinaire, sont primordiales pour une prise en charge thérapeutique multimodale et personnalisée. Cet article a pour but de résumer, de façon pratique, les dernières recommandations des sociétés européennes de cardiologie (ESC) et de pneumologie (ERS) publiées en 2022.

Study design and rationale of a comparison of prasugrel and clopidogrel in medically managed patients with unstable angina/non-ST-segment elevation myocardial infarction: the TaRgeted platelet Inhibition to cLarify the Optimal strateGy to medicallY manage Acute Coronary Syndromes (TRILOGY ACS) trial.

Practice guidelines recommend dual antiplatelet therapy with aspirin and clopidogrel for patients with non-ST-segment elevation acute coronary syndromes (NSTE ACS) regardless of in-hospital management strategy. Prasugrel-a thienopyridine adenosine diphosphate receptor antagonist that provides higher and less variable levels of platelet inhibition than clopidogrel-has demonstrated benefit when used to treat ACS patients undergoing percutaneous coronary intervention. However, the optimal approach to antiplatelet therapy for high-risk, medically managed NSTE ACS patients remains uncertain, as these patients have not been the focus of previous clinical trials of these therapies. TRILOGY ACS is a phase 3, randomized, double-blind trial enrolling approximately 10,300 NSTE ACS patients within 10 days of presentation with either unstable angina or NSTE myocardial infarction who are not intended to undergo revascularization procedures for their index event. Patients will be randomly allocated to prasugrel + aspirin versus clopidogrel + aspirin for a median duration of 18 months. A reduction in the maintenance dose of prasugrel for elderly patients (age >or=75 years) and those with body weight <60 kg is planned. The primary composite efficacy end point will be time to first occurrence of cardiovascular death, myocardial infarction, or stroke in patients aged <75 years. If the superiority of prasugrel is established in patients aged <75 years, the treatment arms will then be compared for all subjects (including those aged >or=75 years). TRILOGY ACS is the largest randomized clinical trial to date focusing exclusively on medically managed NSTE ACS patients and will provide important information regarding the optimal approach to oral antiplatelet therapy for this high-risk, understudied population.

Prasugrel compared with high-dose clopidogrel in acute coronary syndrome. The randomised, double-blind ACAPULCO study.

Compared with the approved dose regimen of clopidogrel (300-mg loading dose [LD], 75-mg maintenance dose [MD]), prasugrel has been demonstrated to reduce ischaemic events in patients with acute coronary syndrome (ACS) undergoing percutaneous coronary intervention (PCI). In ACS, antiplatelet effects of a prasugrel MD regimen have not been previously compared with either a higher clopidogrel MD or after switching from a higher clopidogrel LD. The objective of this study was to evaluate the antiplatelet effect of a prasugrel 10-mg MD versus a clopidogrel 150-mg MD in patients with ACS who had received a clopidogrel 900-mg LD. Patients with non-ST elevation ACS, treated with aspirin and a clopidogrel 900-mg LD, were randomised within 24 hours post-LD to receive a prasugrel 10-mg or clopidogrel 150-mg MD. After 14 days of the initial MD, subjects switched to the alternative treatment for 14 days. The primary endpoint compared maximum platelet aggregation (MPA, 20 microM adenosine diphosphate [ADP]) between prasugrel and clopidogrel MDs for both periods. Responder analyses between treatments were performed using several platelet-function methods. Of 56 randomised subjects, 37 underwent PCI. MPA was 26.2% for prasugrel 10 mg and 39.1% for clopidogrel 150 mg (p<0.001). The prasugrel MD regimen reduced MPA from the post-900-mg LD level (41.2% to 29.1%, p=0.003). Poor response ranged from 0% to 6% for prasugrel 10 mg and 4% to 34% for clopidogrel 150 mg. Thus, in ACS patients a prasugrel 10-mg MD regimen resulted in significantly greater platelet inhibition than clopidogrel at twice its approved MD or a 900-mg LD.