[Effects of preceding stable or unstable angina on hospital morbidity-mortality of myocardial infarction. Results of a continuous series of 1,910 patients]. / Influence de l'angor préalable stable ou instable sur la morbidité-mortalité hospitalière de l'infarctus du myocarde. Résultats d'une série continue de 1,910 patients.

The aim of this study was to determine the effect of preceding unstable angina on the short-term prognosis of myocardial infarction based on early complications: cardiac failure, cardiac rupture, ventricular septal defect, sustained ventricular tachycardia ventricular fibrillation and hospital mortality. A continuous series of 1,910 patients admitted with 7 days of myocardial infarction was analysed retrospectively. The patients were divided into two groups according to their previous coronary history: Group A (myocardial infarction preceded by unstable angina) and Group B (myocardial infarction without preceding unstable angina). Group B was subdivided into Group B1 (myocardial infarction de novo) and Group B2 (myocardial infarction with previous stable angina). The results showed that patients with previous unstable angina (Group A) had a lower hospital mortality (7.9%) than those without (Group B) (13.3%) (p = 00017), fewer cardiac ruptures (1.1 versus 2.9%, p = 0.03) and less ventricular fibrillation (2.6 versus 4.5%, p = 0.053). Subgroups analysis showed that patients with de novo myocardial infarction (Group B1) had more sustained ventricular tachycardia than those with previous stable angina (Group B2) (5.3 versus 2.7%, p = 0.04). The authors conclude that pre-infarction unstable angina, possibly by ischaemic pre-conditioning, is an independent factor of a better prognosis in myocardial infarction.

[Association of D-dimer and helicoidal thoracic scanner for diagnosis of pulmonary embolism. Prospective study of 106 ambulatory patients]. / Association D-dimères et scanner thoracique hélicoïdal pour le diagnostic d'embolie pulmonaire. Etude prospective chez 106 patients ambulatoires.

OBJECTIVE: Ventilation/perfusion pulmonary scintigraphy (PS), the current mainspring in the diagnosis of pulmonary oedema (PE), is frequently non-conclusive. The objective of this study was to determine, prospectively, the diagnostic value of the association of D-dimers and helicoidal thoracic scanner (HTS) in a continuous series of ambulatory adults with suspected PE and admitted to a cardiologic emergency unit. METHODS: Exclusion criteria were as follows: symptoms or clinical signs of seventy, contraindication for HTS and/or on pulmonary angiography, curative anticoagulant therapy for more than 48 hours, history of PE less than 3 months before or the impossibility of conducting all the examinations with 48 hours. All the patients underwent determination of D-dimers by rapid ELISA test, HTS and 2 reference examinations, venous Doppler of the lower limbs and a PS, completed by pulmonary angiography if the PS did not permit diagnosis and the venous Doppler was negative. RESULTS: One hundred and six patients were selected over a recruitment period of 18 months. The prevalence of PE was of 45% (48/106). Forty-four of the 48 PE of the series were central form. HTS was considered dubious in 10 patients (10.4%, PE+ n = 2, PE- n = 8). The results of D-dimers were negative in only 34.5% patients without PE (20/58). Pulmonary angiography was necessary in 15 patients. The negative and positive predictive values of D-dimers were respectively of 100 and 55.8% (48/86) and those of HTS respectively 100 (46/46) and 92% (46/50). CONCLUSION: The diagnostic strategy of clinical suspicion of PE, starting with determination of D-dimers by rapid ELISA test followed by helicoidal thoracic scanner in the case of a positive result, was particularly effective in this series of patients with a high prevalence of PE. These results must be confirmed in a larger series and in a general emergency unit.

[Gene therapy with VEGF]. / Apport de la thérapie génique par le VEGF.

UNLABELLED: NEW THERAPEUTIC OPTION: Atherosclerosis-related conditions are the primary cause of mortality in western countries. The incidence of severe limb-threatening ischemia of the lower limbs reaches 500 to 1000 per million inhabitants. The lack of effective treatment capable of preventing amputation in the most severe cases has led to research into the development of collateral circulation to replace the occluded arteries. Preclinical data has demonstrated that angiogenic factors can stimulate collateral circulation. This new therapeutic approach is called "angiogenesis therapy". VEGF: Vascular endothelial growth factor (VEGF) is a DNA fragment coding for a protein that has raised great expectations which are now entering the era of reality. Several administration routes are possible. The DNA fragments can be deposited on the arterial wall using a catheter. The hydrogel balloon operates like an angioplasty balloon covered with a hydrophilic layer which delivers the DNA fragments when inflated. More recently, the intramuscular route has been used to take advantage of the vascular distribution of this angiogenic cytokine. The peripheral muscle cells can perform the transformation via transcription to a messenger RNA for translation into the human DNA protein. A real application of gene therapy. PERSPECTIVES: Undeniable clinical benefit observed in the limited number of patients treated has led to proposing angiogenic cytokines for the treatment of ischemic heart disease when angioplasty or bypass surgery. The most recent series are small, but show that intramyocardial injection of VEGF is feasible. Larger randomized series will evaluate these techniques. Despite the large body of preclinical data, many questions remain unanswered.

[Comparison of coronary angiography by the left radial and right femoral approach with 4 French catheters]. / Comparaison de la coronarographie par voie radiale gauche et fémorale droite avec des sondes 4 french.

The radial arterial approach has been shown to be valuable for coronary angioplasty. The aim of this study was to evaluate the use of the left radial and right femoral approaches for diagnostic coronary angiography. The authors performed a prospective non-randomised series of consecutive diagnostic coronary angiogrammes with small calibre (4 french) catheters by the left radial (100 patients) and right femoral (100 patients) arteries. The feasibility, results and complications were compared. The study showed that diagnostic coronary angiography with 4 F catheters is feasible with a high success rate, both from the left radial (99%) and right femoral (100%) approaches (NS). The duration of the procedure tends to be longer when the radial approach is used (19.2 +/- 1.3 min) than by the femoral artery (16.3 +/- 1.1 min) (p = 0.06). The duration of irradiation is longer with the radial approach (6.7 +/- 1.2 vs 4.9 +/- 0.9 min) (p = 0.0001). Local complications are minor by either approach (N = 5 vs N = 6 patients; p = NS), and there were no major complications. The tolerance of the procedure was not as good when the radial artery was used (N = 5) compared with the femoral artery (N = 1 patient) because of arterial spasm when the catheters were changed. The authors conclude that the left radial and right femoral arteries can be used routinely for diagnostic coronary angiography with small catheters (4 French). The left radial approach allows immediate mobilisation of the patient but the duration of the procedure and the exposure to irradiation are longer.

[Hospital results of salvage angioplasty with coronary stenting after failure of thrombolysis in the acute phase of myocardial infarction]. / Résultats hospitaliers de l'angioplastie de sauvetage avec implantation d'endoprothèses coronaires après échec de thrombolyse à la phase aiguë de l'infarctus du myocarde.

Between December 1991 and February 19999, 25 patients (56 +/- 10 years) underwent salvage angioplasty with coronary stenting after failure of thrombolysis (TIMI 2), rtPA (N = 18), n-PA (N = 4), K2-tu-PA (N = 2) and streptokinase (N = 1). All were treated by aspirin and 96% were given ticlopidine for one month. The culprit artery was the left anterior descending (48%), the left circumflex (8%) or the right coronary (44%). The average ejection fraction was 41%; 4 patients (16%) had cardiogenic shock. The stents were implanted for occlusive coronary dissection (36%), threatening dissection (40%), partial result of angioplasty (20%) or of first intention (4%). In all, 31 stents were implanted (1.2 +/- 0.57 stent/target lesion ratio with an average length of 20.9 +/- 10.2 mm). The stents were tabular in 51% of cases. The angiographic success rate (TIMI 3 and residual stenosis < 50%) was 96% with maximum inflation pressures of 13.7 +/- 2.5 atm and balloons with an average diameter of 3.3 +/- 0.5 mm. Intra-aortic balloon pumping was required in 7 patients (28%). The 30 day results included a mortality rate of 16% (4 patients), a recurrence of infarction in 4%; there were no repeat angioplasties, coronary bypass surgery or blood transfusions. The predictive factors of recurrent coronary events were: age over 60 (p = 0.04), multivessel coronary disease (p = 0.007), cardiogenic shock (p = 0.004) and left ventricular dysfunction (p = 0.015). The authors conclude that cases of failure of thrombolysis are at high risk and that salvage angioplasty with coronary stenting is associated with excellent angiographic results. Patients with cardiogenic shock, however, have a high mortality, irrespective of coronary patency and the use of intra-aortic balloon pumping.

[Cardiac metastasis of chondrosarcoma: a case report]. / Métastases cardiaques d'un chondrosarcome. A propos d'un cas.

Chondrosarcoma is a primary malignant bone tumour which only exceptionally metastasises to the heart. We report a case of chondrosarcoma with left intracavitary cardiac metastasis discovered following abnormal cardiac auscultation. To our knowledge, only 21 cases have been described in the literature. A lesion of the right atrium is the most frequent event. The major risk of these tumours is their emboligenic properties: pulmonary embolism for metastases of the right heart, systemic embolism for metastases of the left heart. Echocardiography establishes the diagnosis by specifying the site and extent of the tumour. CT scan allows local assessment of the lesions. The course is fatal, although surgery has been able to increase survival of patients with isolated cardiac mestastases.