Central sleep apnea after acute coronary syndrome and association with ticagrelor use.

STUDY OBJECTIVES: By modifying the apneic threshold, the antiplatelet agent ticagrelor could promote central sleep apnea hypopnea syndrome (CSAHS). We aimed to assess the association between CSAHS and ticagrelor administration. METHODS: Patients were prospectively included within 1 year after acute coronary syndrome (ACS), if they had no heart failure (and left ventricular ejection fraction ≥ 45%) and no history of sleep apnea. After an overnight sleep study, patients were classified as "normal" with apnea hypopnea index (AHI) < 15, "CSAHS patients" with AHI ≥ 15 mostly with central sleep apneas, and "obstructive sleep apnea hypopnea syndrome (OSAHS) patients" with AHI ≥ 15 mostly with obstructive sleep apneas. RESULTS: We included 121 consecutive patients (mean age 56.8 ± 10.8, 88% men, mean body mass index 28.3 ± 4.4 kg/m2, left ventricular ejection fraction 56 ± 5%, at a mean of 67 ± 60 days (median 40 days, interquartile range: 30-80 days) after ACS. In total, 49 (45.3%) patients had AHI ≥ 15 (27 [22.3%] CSAHS %, 22 [18.2%] OSAHS). For 80 patients receiving ticagrelor, 24 (30%) had CSAHS with AHI ≥ 15, and for 41 patients not taking ticagrelor, only 3 (7.3%) had CSAHS with AHI ≥ 15 (chi-square = 8, p = 0.004). On multivariable analysis only age and ticagrelor administration were associated with the occurrence of CSAHS, (p = 0.0007 and p = 0.0006). CONCLUSION: CSA prevalence after ACS is high and seems promoted by ticagrelor administration. Results from monocentric study suggest a preliminary signal of safety. CLINICAL TRIALS. GOV ID: NCT03540459.

[Sudden cardiac death in the youth. Is the new subcutaneous implantable cardioverter defibrillator S-ICD an alternative solution?]. / Mort subite du sujet jeune : le défibrillateur sous-cutané S-ICD est-il une solution alternative aux défibrillateurs conventionnels ?

Implantable cardioverter defibrillator (ICD) is well-recognized therapy to prevent sudden cardiac death. Classic ICD need the use of permanent endocavitary leads, which may cause serious troubles (lead dislodgement, ventricular perforation, lead infections, etc.). The subcutaneous implantable cardioverter defibrillator (S-ICD) is a new device provided by only a subcutaneous lead. It has been developed for the last five years and it is becoming at present a real alternative to classic ICD. We report a clinical case of a 34 y.o. woman who presented a sudden cardiac death and who benefited the implantation of this new technology. This paper deals with the potential indications, usefulness benefits, and problems of the S-ICD.

Aortic thrombus and multiple embolisms during a Mycoplasma pneumoniae infection.

We report the case of a patient who presented with a thrombus of the aortic arch complicated with splenic, renal and peroneal artery embolisms, associated with transient lupus anticoagulant, during a Mycoplasma pneumoniae infection. The outcome was good under antibiotic and anticoagulant treatment. We also review the medical literature on M. pneumoniae-related thromboses.

Evaluation of heart failure management in a Military Hospital.

PURPOSE: Evaluate heart failure management in a Military Hospital in 2005. METHODS: Retrospective audit of 46 case records of patients hospitalised with heart failure within the framework of an accreditation procedure. RESULTS: The left ventricular ejection fraction was evaluated in 85% of cases during the reference hospital stay. Systolic heart failure was detected in 63% of cases. At least one NT-proBNP assay was performed for each patient. A global assessment was systematically performed, except for the mini mental state examination in patients aged over 75 years who represented 80% of patients. Initial therapeutic education was provided for 50% of systolic heart failure patients. Prescription rates in systolic heart failure were 76% for angiotensin-converting enzyme inhibitors, 7% for angiotensin receptor antagonists; 84% for at least one medicinal product in the above 2 classes; 68% for beta-blockers and 32% for spironolactone. A hospital discharge report was available for 93% of the patients. Elective re-admissions to hospital for uptitration of treatment concerned 10% of systolic heart failure patients. Emergency hospital re-admissions after a cardiovascular event (usually decompensation), concerned 35% of patients, after an average duration of one year of follow-up. These latter re-admissions, often repeated, led to 4% of additional hospital deaths. The initial hospital mortality rate was 13%. CONCLUSION: Therapeutic patient education is under development. Medication may still be optimised, both qualitatively and quantitatively. Surveillance is planned with a yearly audit.

Coronary heart disease and cardiovascular autonomic neuropathy in the elderly diabetic.

Diabetes and old age come together to increase the frequency and severity of coronary heart disease. Often clinically nearly silent, symptoms frequently manifest dramatically, to such an extent that the question of screening should be raised, as in younger subjects. Preventing these manifestations relies on better management of the cardiovascular risk factors and obtaining good blood glucose control, but here progress remains necessary, which also requires adapting to the older patient's clinical and psychological condition. Cardiovascular autonomic neuropathy is a frequent degenerative complication in diabetics, particularly in the oldest subjects. The most severe types have serious clinical consequences, thus a higher mortality factor, but the mechanisms remain poorly understood. As for coronary heart disease, the therapeutic tools have expanded these last few years and should be thought out in relation to the geriatric evaluation, with the objective of improving these patients' quality of life. Therefore, a necessary distinction should be made between subjects who have aged successfully, whose management, ultimately, differs little from younger subjects, and frail elderly individuals for whom exploratory techniques and treatment should be adapted.

[Rotational coronary angiography]. / Angiographie coronaire rotationnelle.

CONTEXT: Rotational angiography (RA) is a radiological technique that provides multiple views of a vessel for a single injection of contrast. Its significance in the field of coronary angiography is poorly known at present. This study aimed to compare the radiation dose as well as the volume of contrast used during RA compared to standard angiography (SA), and to evaluate its diagnostic precision. METHOD: 78 patients sent for diagnostic coronary angiography were explored using the radial approach. The patients were randomised between RA (3 acquisitions for the left coronary and 1 for the right coronary) or SA. Once a decision to undertake angioplasty had been made following the angiography (RA or SA), the initial study was complemented using the alternative technique (SA or RA) before the angioplasty procedure was performed at a later stage. The severity of the lesions as shown by RA and SA was compared by four experienced coronary angiography operators. RESULTS: 65 patients (mean age 61+/-10 years--mean BMI 26+/-4 Kg/m2) underwent complete RA+SA investigation. The total x-ray dose used during ciné-angiography, the dose received by the patient, and the volume of contrast were significantly reduced in the RA group compared to the SA group (-25%; -36%; -33% respectively). An evaluation of the severity of the stenoses was performed on 168 arterial segments. There was a significant correlation between the two techniques (R=0.95--p<0.001) and the intra-observer variability was non significant (3.7+/-6.8%--p=NS). CONCLUSIONS: Rotational angiography allows the radiation dose and the volume of contrast to be reduced, while retaining a diagnostic precision similar to that of standard angiography.

[Anaesthesia and amiodarone-associated hyperthyroidism]. / Anesthésie et hyperthyroïdie associée à l'amiodarone.

Amiodarone can induce severe hyperthyroidism that justifies its withdrawal and initiation of antithyroid drugs. Impossibility to stop amiodarone, failure to control hyperthyroidism and unfavourable evolution can lead to thyroidectomy. Cardiac manifestations, persistence of hyperthyroidism and interactions between amiodarone and anaesthetic or haemodynamic drugs may contraindicate anaesthesia. We report nine consecutive cases of amiodarone-associated hyperthyroidism that prompted us to perform thyroidectomy under general anaesthesia. The features and anaesthetic data of patients were noted. The antithyroid medical treatment failed in all patients. After thyroidectomy, evolution was favourable in all nine cases, without any intra or postoperative complication, in spite of the extent of hyperthyroidism and the severity of the associated cardiac problems. Despite potential high risks, thyroidectomy for amiodarone-induced hyperthyroidism does not seem to increase morbidity or mortality and allows a quick return to euthyroidism and reintroduction of amiodarone.

Procedural characteristics of primary coronary angioplasty in diabetic patients with acute anterior myocardial infarction.

BACKGROUND: Mortality and morbidity rates are higher in diabetics compared to non-diabetics after acute myocardial infarction (AMI). Previous angiographic studies regarding primary angioplasty for the treatment of AMI found that angioplasty was similarly successful in diabetics and non-diabetics. However, it is noteworthy that patients of "real life" are often far from the population randomised in prospective protocols. The aim of this study was to examine the procedural characteristics of consecutive diabetic patients hospitalised for anterior AMI and treated with primary angioplasty as compared to non-diabetics. METHOD: We analysed 28 consecutive diabetics and 74 non-diabetics who underwent primary angioplasty for anterior AMI (< 12 h from the onset of symptoms) during 15 consecutive months between 2000 and 2001 in our institution, depending on the presence or absence of diabetes. RESULTS: Among analysed data, we found that in diabetics compared to non diabetics: (i) the delay before arrival in the cath-lab was significantly longer (5.5 +/- 2.7 vs 4.2 +/- 2.8 h); (ii) there was a less important collateral flow coming from the non-culprit arteries towards the culprit artery; (iii) there was a less important rate of recovery of a normal flow (TIMI 3) in the culprit artery after coronary angioplasty (67% vs 91%). CONCLUSION: Our study demonstrates that several procedural characteristics could explain the poorer prognosis of AMI treated by primary angioplasty in the diabetic population. The longer delay found in diabetics before arrival in hospital could probably be improved.

[Input of coronary artery calcium score assessed by computed tomography in the screening of diabetic coronaropathy]. / Intérêt du score calcique coronaire par scanner multicoupes dans le dépistage de la coronaropathie diabétique.

The poor prognosis of coronary artery disease along with the inaccuracy of available testing methods have favoured the development of new screening techniques. One such innovation involves measuring the coronary artery calcium score (CAC). Through computed tomography, this test quantifies the amount of calcium deposited in coronary arteries, itself a reflection of the degree of atherosclerosis. This investigation is a prospective study of 48 diabetic subjects comparing the performance of CAC score with the gold standard testing methods. The results of our study showed that, due to its high negative predictive value, 5 invasive tests were performed needlessly as these subjects had very low CAC scores. At this time, the CAC score is not recommended for every patient but rather on a case-by-case basis. However, it may soon emerge as the next step after the ECG in the evaluation of coronary artery disease. This would alleviate the need for more invasive tests in those patients for whom such investigations are deemed unnecessary. The CAC score, when matched for age, sex and other variables, could also serve as an indication for prescribing medications such as statins, along with other therapeutic interventions. Diabetologists, cardiologists and radiologists must work together in order to gain a better understanding of these new techniques. This may facilitate the emergence of a new approach to the treatment of coronary artery disease.

[Importance of transesophageal echocardiography and computed tomography in the differential diagnosis of a case of papillary fibroelastoma revealed by a neurologic accident]. / Intérêt de l'échocardiographie transoesophagienne et du scanner multicoupes dans la démarche diagnostique d'un cas de fibroélastome papillaire révélé par un accident neurologique.

In the light of a new case revealed by a stroke, the authors confirm the importance of transesophagal echocardiography (TEE), and show that multislide computered tomography can be used as a new efficient tool for the diagnosis of cardiac papillary fibroelastoma (CPF). These benign tumours of endocardium are rare and case reports have been published sporadically. Stroke is an usual clinical complication and the most frequent symptom associated with CPF. Transesophageal echocardiography is the reference for diagnosis of CPF when transthoracic echocardiography is normal. When TEE is contraindicated or technically impossible, multislide computered tomography appears as an interesting alternate solution for diagnosis because of its fast acquisition and high spatial resolution. Symptomatology may be connected to either tumoral embolisation or cruoric emboli. Surgery is required for any symptomatic tumour.

Angiographic characteristics of coronary artery disease in diabetic patients compared with matched non-diabetic subjects.

The aim of this study was to assess the extent and the severity of coronary artery disease (CAD) in diabetic patients. Angiographic findings were retrospectively analysed in 50 diabetic and in 50 non-diabetic patients, matched for age and sex, undergoing coronary angiography for evaluation of clinically CAD or silent ischaemia. Baseline characteristics did not show any increase of cardiovascular risk in diabetics compared to the non-diabetic group. Diabetic patients present less chest pain and more electric abnormalities, reflecting CAD specificity for diabetic patients. Angiograms of the coronary tree were divided into 13 segments and two experienced angiographers have developed a methodic analysis of selected coronary segment stenosis. The number of significant coronary artery stenosis (> or = 50%) per patient was higher in diabetic than in non-diabetic subjects (5.06+/-2.16 vs 2.40+/-1.97, p < 0.05). Diabetics had also more left main CAD (7/50 vs 1/50,p < 0.05). Though we did not find at any time statistical difference for multivessel, distal or diffuse CAD between the two groups, nevertheless there are more diffuse and distal lesions of the diabetic coronary artery trees. This debate is not closed, there is always controversy concerning whether the angiographic findings in diabetic or non-diabetic patients are different. But these results corroborate the hypothesis of a greater severity of angiographic proven CAD in diabetic than in non-diabetic patients, especially in the left main coronary artery.

[Postpericardiotomy syndrome; a rare complication of transcavitary cardiac pacing: apropos of a case]. / Syndrome pleuro-péricardique; une complication rare de la stimulation cardiaque par voie endocavitaire. A propos d'un cas.

The authors report a new case of the post-pericardiotomy syndrome occurring after implantation of a DDD pacemaker. This is a rare complication of the insertion of a screw atrial electrode, the iatrogenic potential of which has already been reported. The immediate outcome was favourable with anti-inflammatory therapy.