Should anti-malarial chemoprophylaxis be reimbursed in France? A cost-effectiveness analysis of different reimbursement strategies.

OBJECTIVES: France is the Western country with the highest number of imported malaria cases. This study evaluates the cost and effectiveness of the potential reimbursement of drugs for malaria chemoprophylaxis (CP). It targets travelers with medical insurance in France who are heading to endemic regions in sub-Saharan Africa (SSA), the cost of which is currently fully borne by these travelers. PATIENTS AND METHODS: A decision-tree model was built to assess the cost-effectiveness of three CP reimbursement strategies compared to the current strategy of non-reimbursement from the French National Health Insurance (NHI) perspective. The three strategies targeted either (1) all travelers to SSA (2) travelers of African origin traveling to visit friends and relatives (VFR) and (3) all travelers to West and Central Africa (WCA). Base-case analysis is complemented with deterministic and probabilistic sensitivity analyses (PSA). RESULTS: Reimbursement of CP would lead to a decrease in malaria cases. The base-case incremental cost per additional malaria case prevented (ICER) for strategies 1, 2 and 3 is estimated at € 34,623, € 15,136 and € 23,640, respectively. PSA confirms our results, showing that reimbursement has a very high probability of being cost-effective, especially under strategies 2 and 3. CONCLUSION: Reimbursement of malaria CP by the French NHI could be cost-effective and have a positive effect on malaria prevention in France. Restricting reimbursement to VFRs allows lower ICERs but does not seem feasible in the current French context, while targeting travelers to WCA, who are at higher risk for malaria, could be a reasonably efficient policy.

Clinical impact and evolution of mitral regurgitation after TAVI using the new generation self-expandable valves.

BACKGROUND: Concomitant mitral regurgitation (MR) impaired prognosis in patients undergoing transcatheter aortic valve implantation (TAVI). It has been suggested that the use of first generation self-expandable valve in patients with significant MR is associated with worse outcome as compared with balloon expandable valve. However, the impact of newer generation transcatheter devices on MR has not been investigated so far. We aim to assess the prognostic impact of MR in patients undergoing TAVI with the first-generation vs. the latest generation of self-expandable valves. METHODS: We analyzed 2964 consecutive patients who underwent TAVI. Patients were classified into 4 groups according to the degree of baseline MR and the generation of self expandable valve implanted. RESULTS: Of 1234 patients with moderate or severe MR, 817 were treated with first generation and 417 patients with second generation valves. Whereas, of 1730 patients with no or mild MR, 1130 were treated with first generation and 600 patients with second generation valves. Although, concomitant moderate-severe MR was found to be an independent predictor of mortality after TAVI, the use of newer generation self expandable valves was associated with higher survival rate at 1 year irrespective of the degree of preprocedural MR. At multivariable analysis the use of newer generation valve was associated with MR improvement throughout 1 year follow-up. CONCLUSION: Baseline moderate-severe MR is associated with an increase in mortality after TAVI. However, the degree of preprocedural MR doesn't impact survival when a second generation self expandable valve is used.

Tako-tsubo-like left ventricular dysfunction: transient left ventricular apical ballooning syndrome.

AIMS/OBJECTIVES: This review examines the 'tako-tsubo-like' syndrome or transient left ventricular apical ballooning. The aim of this review is a complete evaluation of epidemiology, clinical and instrumental features, pathophysiological mechanisms, therapy and prognosis of this syndrome. METHODS: We have evaluated the data from literature for a comprehensive consideration of multiple aspects of this syndrome. RESULTS/FINDINGS: Transient left ventricular apical ballooning typically affects women, and the clinical presentation is comparable to acute coronary syndrome with chest pain or sudden dyspnoea, changes in ECG and elevated cardiac enzymes in the absence of significant coronary stenosis, with complete resolution of wall-motion abnormalities in a period of days or weeks. This syndrome is triggered by marked psychological or physiological stress. Several pathophysiological mechanisms have been proposed, such as cathecolamine-mediated cardiotoxicity, abnormalities in coronary microvascular function and multivessel coronary vasospasm. The highest incidence of transient left ventricular apical ballooning is in the Japanese population, but it has been recently identified also in the USA and Europe. Treatment is empirical and supportive. The prognosis is generally favourable, although some deaths have been reported, usually the result of irreversible cardiogenic shock, refractory ventricular arrhythmias, or other catastrophic cardiovascular event. CONCLUSIONS/INTERPRETATIONS: We conclude by emphasising the importance of a more deeper knowledge of this syndrome for general physicians and cardiologists and it should be often considered as a possible diagnosis occurring in emergency department and in patients admitted in the Chest Pain Units with a diagnosis of coronary acute syndrome.

[Homocysteine: a casual link with heart failure?]. / Omocisteina e scompenso cardiaco: un'associazione casuale?

Several studies and recent patents have demonstrated that hyperhomocysteinemia (HHCY) is an independent risk factor for congestive heart failure (CHF); it is also correlated to the severity of the disease. In literature there are some data about effects of HHCY on myocardial structure and function in animal models. These studies indicate a direct effect of HCY in promoting reactive myocardial fibrosis and systolic dysfunction, promoting miocardial redox state, endothelial and mithocondryal dysfunction, negative inotropic effect. According to some authors the HHCY is a potential ethiological factor for heart failure while according to others it is just an epiphenomenon without direct effects on myocardium. Nevertheless the literature studies show the relevant involvement of HHCY in CHF and the strong relations between HHCY plasma levels and the severity and prognosis of the disease. Regarding the potential mechanistic role of HHCY in CHF, all of these studies do not provide any mechanistic insights because of their epidemiological nature. Future studies need to explore the exact pathomechanisms of HHCY in CHF.

Coronary artery fistula: diagnostic role of transthoracic and transesophageal echocardiography.

Congenital coronary artery fistulas (CAFs) are rare. Some patients develop symptoms of congestive heart failure secondary to a large left-to-right shunt or myocardial ischemia from coronary artery steal in the first few years after birth. After the second decade the frequency of symptoms and complications increase. We report a case of CAF originating from the circumflex artery and draining into the coronary sinus, associated with left main coronary aneurysm. Transtho-racic and transesophageal echocardiography approach showed the origin, course, and drainage site of the CAF. This case represents a typical sample of this rare anomaly and puts into evidence the essential role of echocardiography to define and complete the angiographic diagnosis.

[Raised homocysteine plasma concentration in patients with heart failure: clinical significance]. / Elevate concentrazioni plasmatiche di omocisteina in pazienti affetti da insufficienza cardiaca: significato clinico.

UNLABELLED: Elevated plasma levels of homocysteine is associated with increased risk of thrombotic and atherosclerotic vascular disease. Several studies have demonstrated that hyper-homocysteinemia is an indipendent risk factor for vascular disease and is associated to heart failure. However there are no data regarding the association between homocysteine and various objective as well as subjective measures of heart failure. We hypothesized that plasma homocysteine is associated with clinical and echocardiographic signs of heart failure. On this ground we have analysed levels of homocysteine in patients with heart failure and possible correlation between these levels and clinical-functional pattern (NYHA class and ejection fraction). METHODS: Plasma homocysteine levels were determined in 123 patients with dilated cardiomyopathy (59 males, 64 females, mean age 67+/-10 years, mean EF 31+/-11% and mean NYHA 2.4+/-0.9, 47 idiopatic and 76 postischemic cardiomyopathy) and 85 healthy control subjects (homogeneus group for sex and age). Patients with chronic renal failure, vitamin B12 and folate deficiency or factors affecting homocysteine plasma levels were escluded from this study. Homocysteine levels were determined in coded plasma samples by immunoenzimatic methods. RESULTS: Patients with heart failure had a higher homocysteine level (mcg/L) than control subjects (21.72+/-10.28 vs 12.9+/-6.86, p<0,001) both postischemic (20.89+/-9.6 vs 12.9+/-6.86, p<0,001) and idiopatic cardiomiopathy (23.0+/-11.2 vs 12.9+/-6.86, p<0,001). A significant correlation was observed between homocysteine and NYHA functional class (p<0,001), age (p<0,001), creatinine (p<0,001), colesterol (p<0,05) while no correlations were observed with hemodynamic (HR, BP), functional (ejection fraction) and other metabolic parameters (triglycerides). Serum homocysteine was lowest in control and increased with increasing NYHA class. In idiopatic cardiomiopathy the correlation between homocysteine and NYHA functional class, creatinine (p<0,001), fibrinogen (p<0,05) was confirmed; in postischemic cardiomiopathy a significant correlation with creatinine and NYHA class (p<0,001) and with triglycerides (p<0,05) was also found. CONCLUSION: Plasma homocysteine was directly related to NYHA class. This observation may underline the strong relations of plasma homocysteine to congestive heart failure. Further research is indicated to evaluate a causal or non-causal mechanism for this association.

Brain cancer mimicking an acute coronary syndrome.

The authors report the case of a 62-year-old woman admitted to hospital for episodes of chest pain with ischemic abnormalities at ECG without enzyme release. Coronography confirmed a normal coronary tree with mild ascending aortic dilatation. Subsequent diagnostic and clinical examinations resulted normal. Episodes of chest pain and dyspnea persisted over the following days. Administration of nitrates, calcium antagonist, diuretic, antidepressant agents for suspected syndrome X led to partial improvement of clinical symptoms. The patient was discharged from the hospital. A few days later she was referred to the neurology department because of an episode of transient dysarthria, hyposthenia and paresthesis localized to the right lower and upper limbs associated with chest pain. A brain computed tomography showed an expansive solid mass. Nuclear magnetic resonance imaging and stereotaxis biopsy confirmed the etiology of the lesion to be a glioblastoma. The patient died soon thereafter from respiratory and cardiocirculatory arrest.

Plasma homocysteine levels and late outcome in patients with unstable angina.

AIM OF THE STUDY: Previous studies have suggested that total plasma homocysteine (HCY) is an important cardiovascular risk factor because of its interaction with vascular smooth muscle cells, endothelium function, plasma lipoprotein, coagulation factors and platelets. The aim of this study was to evaluate a possible relationship between HCY levels and the severity of coronary artery disease (CAD) and its prognostic value in patients with unstable angina (UA). METHODS AND RESULTS: Ninety-four patients with UA were recruited and underwent coronary angiography and in some cases myocardial revascularization. The primary end point was the severity of CAD. The clinical end points were the recurrence of UA and the compositive end point of the occurrence of cardiac death and re-hospitalization due to acute coronary syndrome. HCY levels were shown to be poorly correlated with the severity of CAD. After 48 months' of follow-up, a graded relationship between HCY levels and recurrence of UA and compositive end point was found (p < 0.001). CONCLUSIONS: In the light of events occurring during the follow-up period, it was concluded that total plasma HCY is a strong predictor of recurrence of UA.

Cardiac arrest due to ventricular fibrillation as a complication occurRing during rigid bronchoscopic laser therapy.

Laser bronchoscopy is a usually well tolerated procedure for the treatment of obstructive lesions on the tracheobronchial tree, with a very low morbidity and mortality rate. Cardiovascular complications, including atrial and ventricular arrhythmias, and myocardial ischemia, have only rarely been reported during laser bronchoscopy. Cardiac arrhythmias during such a procedure are usually well tolerated but occasionally may be life threatening. Here we report a case of a young, female patient affected by Pulmonary Tuberculosis with a cicatricial stenosis of the left main bronchus who developed an episode of prolonged cardiac arrest due to ventricular fibrillation (and no signs of acute myocardial ischemia) during rigid broncoscopic laser-therapy. Underlying Coronary Artery Disease and other cardiac abnormalities were also excluded by subsequent cardiovascular examination. The clinical implications are also discussed.

[Recurrent episodes of acute non-cardiogenic pulmonary edema caused by ingesting hydrochlorothiazide]. / Episodi ricorrenti di edema polmonare acuto non cardiogeno indotti dall'assunzione di idroclorotiazide.

We describe a case of a patient presenting repeated episodes of sudden-onset pulmonary edema each occurring immediately after the ingestion of hydrochlorothiazide. The close temporal relationship between the ingestion of hydrochlorothiazide and the onset of symptoms together with the rapid and full clinical recovery after the interruption of therapy, allowed the diagnosis of drug-induced pulmonary edema and a possible anaphylactoid hypotension. The initially low white blood cell count, associated with hemoconcentration, and the increase in white blood cells during the following 24 hours, is consistent with the hypothesis of intrapulmonary sequestration of granulocytes causing pulmonary edema. The pathogenesis and the cause of the increased pulmonary sensitivity are reviewed and discussed.