[Coordinated management of arterial hypertension]. / Prise en charge coordonnée de l'hypertension artérielle entre le praticien et les spécialistes - Place de la dénervation rénale dans l'HTA résistante.

Despite major therapeutic progress and the numerous poly-pill combinations available on the market today, the control of arterial hypertension remains widely insufficient. A multidisciplinary management putting together internal medicine, nephrology and cardiology specialist offers the best chances for patients to achieve their blood pressure goals, especially when suffering from resistant hypertension despite adequate prescription of the reference tri therapy: ACEI/ARA2 combined with a thiazide-like diuretic and calcium channel blocker. Recent studies and randomized trials from the last five years shed a new light on the value of renal denervation and its efficacy on lowering blood pressure. This will probably lead to the integration of this technique in the next guidelines and improve its adoption over the next years.

Malgré les progrès thérapeutiques et les nombreuses combinaisons médicamenteuses de type « pilule combinée ¼ disponibles de nos jours, le contrôle de l'hypertension artérielle reste insuffisant. Une prise en charge multidisciplinaire reliant la médecine générale, la néphrologie et la cardiologie offre les meilleures chances aux patients de maîtriser leur hypertension artérielle, notamment en cas de résistance à la trithérapie de référence IECA/ARA2, inhibiteur calcique et diurétique de type thiazidique. Dans l'arsenal thérapeutique actuel, la dénervation rénale mérite à nouveau une attention particulière grâce aux avancées de la technique et aux résultats encourageants des études récentes, ouvrant le chemin à son intégration dans les prochaines recommandations internationales.

[Cardio-oncological risk stratification and follow up: a new challenge for the general practitioner]. / Prise en charge cardio-oncologique : un nouveau défi pour le praticien.

Rise of medical oncology, aging of populations and survival rates' improvement of patients suffering from cancer are all factors contributing to exponential rise of the exposure of patients to -cardiotoxic therapies. A multidisciplinary approach including a close cooperation between general practitioner and specialists will -promote an early identification and treatment of cardiovascular complications related to cancer treatments. This strategy has proven to have a truly positive impact on both cardiovascular and onco-logic prognosis. We will summarize throughout this article the last recommendations established by the European Society of Cardiology in terms of cardiovascular risk stratification and follow up planning through the use of clinical, biological and cardiac imaging data.

L'essor de l'oncologie médicale, le vieillissement des populations et l'amélioration de la survie des patients atteints de cancer sont autant de variables qui expliquent l'exposition grandissante à des thérapies anticancéreuses potentiellement cardiotoxiques. Une approche multidisciplinaire entre le médecin de première ligne et les différents spécialistes permettra de prévenir et de repérer ­précocement les complications cardiovasculaires liées aux traitements, avec un impact réel sur le pronostic oncologique et cardiovasculaire. Nous résumons dans cet article les dernières recommandations de la Société européenne de cardiologie en matière de stratification du risque cardiovasculaire à travers l'utilisation de données cliniques, biologiques et de l'imagerie cardiaque.

[The influence of summer temperatures on the incidence of Takotsubo cardiomyopathy : a retrospective study]. / Influence des canicules sur l'incidence du syndrome de Takotsubo : étude rétrospective en Valais.

Takotsubo cardiomyopathy (TK-CM) is a reversible acute left ventricular dysfunction that cannot be explained by an obstructive coronary lesion. The aim of our study was to explore the possible correlation between the incidence of TK-CM in summer and the average temperature, number of heat waves or number of days hotter than 30°C. 482 patients presented an acute coronary syndrome in the summers of 2012 until 2017 in our region. 15 patients met the inclusion and exclusion criteria and were diagnosed as TK-CM. The study analysis showed a statistically correlation between the number of heatwaves and the incidence of TK-CM (coefficient of correlation: 0.77; p = 0.04). This comforts the hypothesis of climatic influence on this pathology.

Le syndrome de Takotsubo (STK) est une dysfonction ventriculaire gauche aiguë, le plus souvent réversible, sans rapport avec une maladie coronarienne. L'objectif de notre étude était d'explorer le lien entre l'incidence de cette maladie en été et divers paramètres météorologiques; température moyenne, nombre de canicules et nombre de jours au-dessus de 30 °C. 482 patients ayant présenté un syndrome coronarien aigu entre les étés 2012 et 2017 ont été analysés dans notre région (Valais, Suisse). Après application des critères d'éligibilité et d'exclusion, 15 avec un STK avéré ont été inclus dans l'étude. Les résultats montrent que l'incidence de STK était statistiquement plus élevée pendant les canicules (coefficient de corrélation: 0,77; p = 0,04), ce qui conforte l'hypothèse de l'influence des températures extrêmes sur l'incidence saisonnière de cette pathologie.

Case report: Mechanical mitral prosthetic valve thrombosis in the context of COVID-19 despite effective anticoagulation.

BACKGROUND: The SARS-CoV2 virus has been an emerging virus since December 2019 and is the cause of a global pandemic whose clinical manifestations extend far beyond respiratory disease. CASE SUMMARY: A patient with severe coronavirus disease 2019 respiratory infection, carrying a mechanical mitral valve and under anticoagulation, was admitted to our cardiology department because of a new atrial fibrillation, which turned out to be related to thrombosis of the mitral mechanical valve. CONCLUSION: The pro-coagulant effect of the SARS-CoV2 virus does not spare patients at risk of thrombosis, even under effective anticoagulation. In patients with mechanical valves under vitamin K antagonist treatment, there is a high risk of thrombus formation. The treatment is based on thrombolysis by therapeutic anticoagulation, fibrinolysis, or surgery depending on the size, composition of thrombus, and clinical manifestation.

Effects of the P-Selectin Antagonist Inclacumab on Myocardial Damage After Percutaneous Coronary Intervention According to Timing of Infusion: Insights From the SELECT-ACS Trial.

BACKGROUND: The Effects of the P-Selectin Antagonist Inclacumab on Myocardial Damage After Percutaneous Coronary Intervention for Non-ST-Segment Elevation Myocardial Infarction (SELECT-ACS) trial suggested beneficial effects of inclacumab, a monoclonal antibody directed against P-selectin, on periprocedural myocardial damage. This study evaluated the effect of inclacumab on myocardial damage according to varying time intervals between study drug infusion and percutaneous coronary intervention (PCI). METHODS AND RESULTS: Patients (n=544) enrolled in the SELECT-ACS trial and randomized to receive 1 infusion of placebo or inclacumab (5 or 20 mg/kg, administered between 1 and 24 hours before PCI) were divided according to the time interval between study drug infusion and PCI. The primary end point was the change in troponin I from baseline at 16 and 24 hours after PCI. In patients receiving inclacumab 20 mg/kg with a short (less than median) time interval between infusion and PCI, placebo-adjusted geometric mean percent changes in troponin I, creatine kinase-myocardial band, and peak troponin I at 24 hours were -45.6% (P=0.005), -30.7% (P=0.01), and -37.3% (P=0.02), respectively. No significant changes were observed in patients with a long (greater than median) time interval between infusion and PCI. Placebo-adjusted geometric mean percent changes in troponin I and creatine kinase-myocardial band were -43.5% (P=0.02) and -26.0% (P=0.07), respectively, when inclacumab 20 mg/kg was administered between 1 and 3 hours before PCI, whereas the drug had no effect with longer intervals. CONCLUSIONS: Inclacumab 20 mg/kg significantly reduces myocardial damage after PCI in patients with non-ST-segment elevation myocardial infarction, and benefits are larger when the infusion is administered <3 hours before PCI. CLINICAL TRIAL REGISTRATION: URL: http://www.clinicaltrials.gov. Unique identifier: NCT01327183.

Impact of participation in randomized trials of reperfusion therapy on the time to reperfusion and hospital mortality in ST-segment elevation myocardial infarction: A single-centre cohort study.

AIM: There is uncertainty as to whether consenting and randomizing patients in randomized clinical trials (RCTs) in acute ST-segment elevation myocardial infarction (STEMI) delays reperfusion and increases mortality. The aim of this study was to determine whether participation of patients with STEMI in RCTs is associated with delay in implementation of reperfusion therapy and increased hospital mortality. METHODS AND RESULTS: A consecutive sample of 2523 patients, admitted within 6 hours of symptom onset without cardiogenic shock, was recruited from a single tertiary academic centre. They were categorized according to participation (n=392, 15.5%) or nonparticipation (n=2131, 84.5%) in RCTs of reperfusion therapy. Primary outcome was hospital mortality. Additional outcome was time from symptom onset to receipt of reperfusion therapy. Trial participants were more likely to receive fibrinolysis with a 37 min delay in comparison with patients not included in RCTs. Time from symptom onset to reperfusion (minutes) was longer for trial participants than nonparticipants (246 ± 85 vs 233 ± 93, p=0.01). Hospital mortality was 3.61% for nonparticipants. Expected mortality (based on risk modeling) for trial participants was 2.74% (p=0.014 vs nonparticipants). Observed mortality was 1.53% (p=0.034 vs nonparticipants; p=0.16 vs expected mortality). In a multivariable analysis using logistic regression, participation in a RCT was not an independent correlate of hospital mortality (odds ratio 0.54, 95% confidence interval 0.23-2.43, p=0.16). CONCLUSIONS: In this consecutive cohort, despite a longer delay to reperfusion, there was no indication that participation in a RCT, starting before initiation of reperfusion therapy, was associated with a detectable increase in risk of hospital mortality among patients with STEMI. These data suggest that it is possible to consent and randomize patients with STEMI into RCTs without jeopardizing their survival.

[News about pericardial diseases in 2016]. / Maladies du péricarde : quoi de neuf en 2016 ?

The European Society of Cardiology published in 2015 the new Guidelines on the management of pericardial diseases. Based on experts' opinions and recent clinical studies of respectable size, the new guidelines thoroughly revisit the criteria for hospitalization and precisely define severe cases. Another highlight regards medication. From now, first-line medical therapy should include the association of colchicine to the traditional non steroidal anti-inflammatory drugs or aspirin. The bi-therapy is recommended as soon as the first episode of pericarditis, for duration of 3 months. The experts also recommend systematically performing a heart ultrasound for any form of pericardial disease and restricting physical activities especially if myocardial damage (perimyocarditis) is associated.

La Société européenne de cardiologie a publié de nouvelles recommandations en 2015 à propos des maladies du péricarde, apportant des précisions au niveau des thérapies avec notamment l'introduction en première ligne de la colchicine en association aux anti-inflammatoires non stéroïdiens (AINS) ou à l'aspirine, et ce dès le premier épisode de péricardite idiopathique. Les corticoïdes restent contre-indiqués en première ligne. Les experts préconisent en outre la réalisation systématique d'une échocardiographie cardiaque. Les critères d'hospitalisation sont précisés (fièvre, échec du traitement aux anti-inflammatoires non stéroïdiens) et il est rappelé la nécessité d'une restriction au niveau des activités sportives, en particulier lors d'une atteinte associée du myocarde.

Effects of the P-selectin antagonist inclacumab on myocardial damage after percutaneous coronary intervention for non-ST-segment elevation myocardial infarction: results of the SELECT-ACS trial.

OBJECTIVES: The study aimed to evaluate inclacumab for the reduction of myocardial damage during a percutaneous coronary intervention (PCI) in patients with non-ST-segment elevation myocardial infarction. BACKGROUND: P-selectin is an adhesion molecule involved in interactions between endothelial cells, platelets, and leukocytes. Inclacumab is a recombinant monoclonal antibody against P-selectin, with potential anti-inflammatory, antithrombotic, and antiatherogenic properties. METHODS: Patients (N = 544) with non-ST-segment elevation myocardial infarction scheduled for coronary angiography and possible ad hoc PCI were randomized to receive 1 pre-procedural infusion of inclacumab 5 or 20 mg/kg or placebo. The primary endpoint, evaluated in patients who underwent PCI, received study medication, and had available efficacy data (n = 322), was the change in troponin I from baseline at 16 and 24 h after PCI. RESULTS: There was no effect of inclacumab 5 mg/kg. Placebo-adjusted geometric mean percent changes in troponin I with inclacumab 20 mg/kg were -24.4% at 24 h (p = 0.05) and -22.4% at 16 h (p = 0.07). Peak troponin I was reduced by 23.8% (p = 0.05) and area under the curve over 24 h by 33.9% (p = 0.08). Creatine kinase-myocardial band yielded similar results, with changes of -17.4% at 24 h (p = 0.06) and -16.3% at 16 h (p = 0.09). The incidence of creatine kinase-myocardial band increases >3 times the upper limit of normal within 24 h was 18.3% and 8.9% in the placebo and inclacumab 20-mg/kg groups, respectively (p = 0.05). Placebo-adjusted changes in soluble P-selectin level were -9.5% (p = 0.25) and -22.0% (p < 0.01) with inclacumab 5 and 20 mg/kg. There was no significant difference in adverse events between groups. CONCLUSIONS: Inclacumab appears to reduce myocardial damage after PCI in patients with non-ST-segment elevation myocardial infarction. (A Study of RO4905417 in Patients With Non ST-Elevation Myocardial Infarction [Non-STEMI] Undergoing Percutaneous Coronary Intervention; NCT01327183).

Clinical value of drugs targeting inflammation for the management of coronary artery disease.

Atherosclerosis and cardiovascular disease are the leading cause of death worldwide. Atherosclerosis is a complex inflammatory disease that results from lipid accumulation and oxidation in the arterial wall combined with an active inflammatory reaction involving transmigration of monocytes and other inflammatory cells from the blood stream into the vessel wall. Many therapeutic approaches have been tested to treat atherosclerosis and prevent its complications, with statins being the most efficient therapy by reducing the levels of atherogenic lipoproteins and preventing major cardiovascular events. However, the risk of atherothrombotic complications still remains high, causing millions of deaths around the world each year. Extensive research has shed light on the cascade of cellular and molecular events that lead from atherosclerotic plaque formation to its rupture and have highlighted promising new therapeutic targets, each being implicated at different stages of the atherosclerotic plaque formation and progression. In this review, we briefly discuss the potential of high-density lipoprotein-based therapies, given the anti-inflammatory properties of high-density lipoprotein. We then present different approaches that tackle inflammation, including inhibition of 5-lipoxygenase, blockade of P-selectin, use of a viral-derived serpin, and interleukin-1ß inhibition. All these targets have shown encouraging results in clinical trials and support the idea that targeting inflammation could reduce cardiovascular complications in patients with coronary artery disease.