Is the duration of dual antiplatelet therapy (DAPT) excessive in post-angioplasty in chronic coronary syndrome? Data from the France-PCI registry (2014-2019).

Background: while the duration of dual antiplatelet therapy (DAPT) following coronary angioplasty for chronic coronary syndrome (CCS) recommended by the European Society of Cardiology has decreased over the last decade, little is known about the adherence to those guidelines in clinical practice in France. Aim: To analyze the real duration of DAPT post coronary angioplasty in CCS, as well as the factors affecting this duration. Methods: Between 2014 and 2019, 8.836 percutaneous coronary interventions for CCS from the France-PCI registry were evaluated, with 1 year follow up, after exclusion of patients receiving oral anticoagulants, procedures performed within one year of an acute coronary syndrome, and repeat angioplasty. Results: Post-percutaneous coronary intervention (PCI) DAPT duration was > 12 months for 53.1% of patients treated for CCS; 30.5% had a DAPT between 7 and 12 months, and 16.4% a DAPT ≤ 6 months. Patients with L-DAPT (>12 months) were at higher ischemic risk [25.0% of DAPT score ≥2 vs. 18.8% DAPT score ≥2 in S&I-DAPT group (≤12 months)]. The most commonly used P2Y12 inhibitor was clopidogrel (82.2%). The prescription of ticagrelor increased over the period. Conclusions: post-PCI DAPT duration in CCS was higher than international recommendations in the France PCI registry between 2014 and 2019. More than half of the angioplasty performed for CCS are followed by a DAPT > 12 months. Ischemic risk assessment influences the duration of DAPT. This risk is probably overestimated nowadays, leading to a prolongation of DAPT beyond the recommended durations, thus increasing the bleeding risk.

[Prostheses used in tavi]. / Les différentes prothèses pour le TAVI.

Since the first human implantation of a percutaneous aortic valve in 2002, tavi prosthesis didn't stop to improve their results. These improvements allowed to decrease dramatically tavi's complications and to extend the technic to patients with mid indeed low surgery risk. So tavi became the first treatment of aortic stenosis in France since a few years.

[Asymptomatic carotid stenoses. A cardiologist's viewpoint]. / Sténoses carotidiennes asymptomatiques.

Cardiologist work is undergoing profound changes. He is in charge of the prevention and treatment of atherothrombotic disease. Preoperative evaluation of global cardiovascular risk is of paramount importance to choose between medical, surgical or interventional treatment. Furthermore, because the cardiologist has extensive experience with coronary angioplasty, he will have an essential role in carotid angioplasty.

One-month results of coronary stenting in patients > or = 75 years of age.

Coronary artery bypass operations are associated with increased morbidity and mortality in the elderly. Similarly, it has been shown that coronary angioplasty is associated with a higher risk of complications in the elderly than in younger patients. The purpose of this study was to evaluate the 1-month outcome of elderly patients (>75 years old) who were included in the Stenting without Coumadin French Registry. From December 1992 to March 1995, 2,900 patients (mean age 61+/-11 years) were included in this registry. All patients were treated with ticlopidine (250 to 500 mg/day) for 1 month from the day of percutaneous transluminal angioplasty, aspirin (100 to 250 mg/day) for >6 months, and low-molecular-weight heparin (antiXa 0.5 to 1 IU/ml) for 1 month in phase II, 15 days in phase III, and 7 days in phase IV. No heparin was given in phase V. The study group included 233 patients (8.0%) > 75 years old (mean age 79+/-4), 44 (18%) of whom were women. All patients underwent dilatation of a native coronary vessel. One hundred seventeen had unstable angina (50.2%), 20 had postmyocardial infarction ischemia (8.6%), and 6 had acute myocardial infarction (2.6%). Indications for stenting were de novo lesion in 63 patients (27.0%), restenosis in 38 (16.3%), suboptimal result in 48 (20.6%), nonocclusive dissection in 56 (24.0%), and occlusive dissection in 28 (12.0%), respectively. Stented coronary arteries were the left anterior descending in 109 (46.8%), the right in 80 (34.3%), the left circumflex in 40 (17.2%), and the left main in 4 (1.7%). Palmaz-Schatz stents were used in 228 patients (82.0%), AVE microstents in 38 (13.7%), and other stents in 12 (4.3%). More than 1 stent was used in 48 patients (17.3%). The mean diameter of the balloon used for stenting was 3.31+/-0.38 mm and maximal inflation pressure was 12.2+/-2.9 atm. At one-month follow-up, vascular complications occurred in 5 patients, requiring surgery in 2 (1.3%), acute closure occurred in 1 (0.4%), subacute closure in 3 (1.3%), emergency or planned coronary artery bypass graft surgery in none, acute myocardial infarction in 4 (1.7%), stroke in 1 (0.4%), and death in 8 (3.4%). The composite end point of a major cardiac event was observed in 13 cases (5.6%). Coronary stenting using ticlopidine and aspirin appears to be a particularly safe approach in this high-risk subset.

[Long-term prognosis of coronary artery spasm]. / Pronostic à long terme du spasme artériel coronaire.

This study analyses the long-term prognosis of 210 patients with coronary spasm documented at coronary angiography. All patients with a previous history of myocardial infarction or who had undergone coronary angioplasty were excluded. The average follow-up was 55 months and only 11 patients were lost to follow-up. The actuarial survival figures showed the 1 year, 2 year and 5 year survival rates to be 95, 92 and 89 per cent respectively. Extracardiac mortality was mainly related to smoking (lung cancer, laryngeal cancer, etc.) and was higher than cardiac mortality. More than half of the cardiovascular events (sudden death, myocardial infarcts) occurred during the first year of follow-up. Ten patients (4.7%) died suddenly. The predictive factors of this event were: previous syncopal episodes or syncopal angina due to coronary spasm, percritical arrhythmias and the documentation of multiple spasms at coronary angiography. Myocardial infarction was observed in 10.6 per cent of patients. Only those with significant coronary arterial lesions developed this complication. At the end of the follow-up period, 75 per cent of patients were asymptomatic or had only atypical chest pain. No significant differences were observed between the two groups treated medically, by aortocoronary bypass or by the association of coronary bypass and plexectomy with the exception of non-lethal myocardial infarcts being significantly less common in patients treated medically. Therefore, the long-term prognosis of patients with coronary spams is relatively satisfactory.

[Value of negative U waves in coronary artery spasm]. / Intérêt de l'onde U négative dans le spasme artériel coronaire.

The significance of U-wave inversion during coronary arterial spasm was investigated in 188 consecutive ergometric tests performed in 69 patients. All patients had previously undergone coronary arteriography which had clearly shown coronary spasm either at rest or after a single 0.4 mg injection of ergometrine. The ergometrine tests were then performed at the patient's bedside using a standard protocol with injection of incremental doses of ergometrine: 0.05, 0.1, 0.2 and 0.4 mg every 5 minutes with 12-lead ECG recordings every minute. Fifty of the 59 patients with positive tests had classical signs of spasms: ST elevation or depression and/or T wave inversion; the other 9 patients had inversion of the U wave alone (2 cases) or associated with classical ST segment changes in the remaining cases. The 10 other patients had no ECG changes although 2 of them suffered typical anginal pain. Negative U waves were observed in 4 of the 12 patients with spasm of the left anterior descending artery, accompanied by ST elevation in the anterior wall leads. A negative U wave would appear to be a sign of less ischaemia than the classical ECG changes because anginal pain is less common: 4 out of 9 cases in which U wave inversion was a very early change, 8 out of 9 cases in which it was the first or only abnormality. The recognition of a negative U wave increases the sensitivity of the electrocardiogram during resting angina and allows earlier treatment of coronary spasm with nitrate derivatives after an ergometrine test.

Abnormal diffuse coronary vasomotion.

Although coronary artery spasm and abnormal vasoconstriction have undergone considerable investigation, it remains difficult to assess coronary vasomotor tone. To address this problem, the combination of two pharmacological tests (IV injection of 0.4 mg ergometrine followed 5 min later by IV injection of 3 mg isosorbide dinitrate) was performed after the routine procedure of coronary arteriography. Two indexes were defined: total coronary vasomotion (TCV) and maximal total coronary vasomotion (max TCV). These indexes were measured in 20 normal subjects and the normal values were 28.2 +/- 14% and 50.8 +/- 19.2% respectively. Among the 2758 patients who underwent the two tests, a group of 40 patients with normal coronary arteries, no focal spasm and diffuse abnormal coronary vasomotion (DAV) was identified. Eleven patients had vasoconstriction and vasodilatation within the normal range and were identified only by the combination of the 2 tests. All the 40 patients complained of angina at rest and three had had a previous myocardial infarction in the area supplied by the vessel with DAV. During a spontaneous episode of pain at rest 7 patients had ST segment elevation, and 7 a T wave inversion. Thus, these indexes of total coronary vasomotion could be useful to identify patients with abnormal vasomotor tone which could not be detected by the conventional provocative tests.

Percutaneous coronary rotational angioplasty in humans: preliminary report.

Percutaneous coronary rotational angioplasty was attempted in 12 patients. The procedure was performed with a flexible rotating shaft with an abrasive tip, varying in diameter from 1.25 to 3.5 mm, tracking along a central guide wire. Among the 12 patients (mean age 58 years), 4 had a stenosis in the left anterior descending coronary artery and 8 a stenosis in the right coronary artery. After the guide wire crossed the stenosis, the abrasive tip was slowly advanced and several passes across the stenosis were made. The residual stenosis was measured with computerized automatic quantitative coronary angiography. Success was defined as a reduction of percent stenosis by greater than 20%. If residual stenosis remained significant (greater than 50%), the procedure was completed by balloon dilation. The device could not be inserted in 2 of the 12 patients. Five of the 10 patients underwent rotational angioplasty alone, and 5 had the procedure completed by balloon dilation. The stenosis was significantly enlarged from 0.56 +/- 0.31 mm to 1.26 +/- 0.28 mm. The outline of the vessel appeared smooth and regular. There were no complications related to the procedure and all patients were free of symptoms when discharged 2 to 3 days after the procedure. Thus, coronary rotational angioplasty is a simple and safe procedure allowing marked dilation of the narrowed segment. However, long-term follow-up is required for further evaluation.

Percutaneous aspiration of a coronary thrombus.

Right coronary artery occlusion by a thrombus occurred during the coronary angiography performed in a patient with anterior myocardial infarction. Emergency coronary aspiration was undertaken via a 9F guiding catheter, which allowed the thrombus to be removed. The patient, who was in cardiogenic shock, immediately improved and was subsequently discharged without any complications or sequelae.

[Predictive value of exercise-induced ST depression in the diagnosis of restenosis after coronary angioplasty]. / Valeur prédictive du sous-décalage de ST à l'effort dans le diagnostic de la resténose après angioplastie coronaire.

Exercise tests systematically performed during coronary arteriography in patients who had undergone coronary angioplasty show a very large number of ST depressions in the absence of significant coronary lesion. This could be ascribed either to electrocardiographic traces of chronic ischaemia or to a reduced predictive value of exercise tests due to a combination of low prevalence of coronary disease and poor specificity and/or sensitivity. In order to confirm or infirm these hypotheses, the values observed in a study group of 122 patients who had undergone angioplasty for single lesion of the anterior interventricular artery were compared with the values calculated by Bayes' theorem from a 30 p. 100 theoretical restenosis rate and a sensitivity and specificity calculated from a group of control patients who did not have coronary angioplasty but showed the same coronary arteriographic characteristics as the study group. In the study group as in the control group, sensitivity (60 versus 67 p. 100) and specificity (56 versus 54 p. 100) were low. Positive predictive values were also very low (33 versus 38 p. 100), whereas negative values were acceptable (78 p. 100 in both groups). Differences between groups were not significant. The predictive value of ST depression in the diagnosis of post-angioplasty restenosis is too low to be used alone. This low predictive value can be ascribed to the low prevalence of restenosis and to the extremely low specificity observed in the presence of non significant lesions. However, the finding of a negative exercise test in asymptomatic patients enables coronary arteriography to be avoided with a low risk of error (7.7 p. 100).

[Cross-over double-blind study of verapamil versus diltiazem in effort myocardial ischemia]. / Etude croisée en double aveugle du vérapamil contre diltiazem dans l'ischémie myocardique d'effort.

There is a number of factors in favor of a different effect between the two main calcium-blockers causing bradycardia. The effects of 3 doses of verapamil 120 mg and 3 doses of diltiazem 60 mg, were compared in a double-blind study with cross-over, in 12 patients with coronary insufficiency diagnosed by coronary angiography. Four stress tests were performed in each patient, two with placebo before each treatment period and two after treatment, according to the Bruce protocol, using a computerized ECG reading system. As compared with the placebo, the two products decrease the myocardial oxygen needs, increase the duration of the stress and improve the baseline offset of the ST segment. The ischemia, demonstrated by the baseline offset of the ST segment, appears significantly less with verapamil than with diltiazem.

Relation to restenosis after percutaneous transluminal coronary angioplasty to vasomotion of the dilated coronary arterial segment.

Among 868 patients with successful percutaneous transluminal coronary angioplasty (PTCA), 437 were restudied angiographically and had a provocative test with ergonovine during coronary angiography performed before and 6 months after the procedure. The relation between provoked coronary artery spasm and restenosis was studied and 4 groups of patients were analyzed. Those in group 1 (n = 63) had spasm before and after PTCA and their rate of restenosis was high (55%), especially when spasm after PTCA was observed on the dilated coronary segment (restenosis rate 58%). Patients in group 2 (n = 78) had spasm before PTCA but without abnormal vasoconstriction at 6 months and their incidence of restenosis was 19%. Sixty-one patients in group 3 had no spasm before PTCA but developed spasm at restudy. The rate of restenosis was high (38%) in this group, especially when the spasm after PTCA was located on the dilated segment (43%). In group 4 (n = 235), patients had no spasm before or after PTCA and the restenosis rate was 20%. Thus, the presence of coronary artery spasm on the dilated coronary segment, 6 months after a successful PTCA, is frequently accompanied (43% in group 3 and 58% in group 1) by restenosis.

[Cardiac manifestations of Lyme disease. Apropos of a case]. / Manifestations cardiaques de la maladie de Lyme. A propos d'un cas.

A new case of heart involvement in Lyme's disease is reported. Its originality lies in its strictly isolated nature, therefore revealing the disease; in its typical picture of myocardopericarditis combining, in various stages, infra-hissian conduction disorders, bouts of left ventricular insufficiency, pseudoischemic repolarisation disorders and finally a moderate pericardial shift; in the demonstration, during two successive heart explorations by NMR (Nuclear Magnetic Resonance), of a diffuse myocardial hypertrophy, subsiding in time, as the other symptoms of this patient.

[A new method of laser angioplasty by contact sapphire: preliminary results. Apropos of 20 cases]. / Nouvelle méthode d'angioplastie laser par saphir de contact des artères périphériques: résultats préliminaires. A propos de 20 cas.

We report our first 20 cases of peripheral laser angioplasty using an optic fibre with contact sapphire tip. The equipment included a teflon catheter on which was screwed a round sapphire 2.2 mm in diameter. A 600 microns optic fibre connected to a Nd-Yag laser instrument was introduced into the catheter and placed in contact with the sapphire. Twenty patients underwent recanalization of femoral or popliteal arteries occluded on a length of 5 to 45 cm. The sapphire-tipped catheter was introduced by the Seldinger technique up to the site of occlusion. The 15 watt laser emission was set at intervals of one second. Sixteen out of the 20 occluded arteries were recanalized. Among the 4 failures, 3 were due to perforation and 1 to intraparietal progression. Angioplasty was performed with laser alone in 3 cases and with laser completed by balloon catheter in 13 cases. The minimum diameter of the laser-induced channel was 2 mm and was significantly increased (3.8 mm) by complementary balloon dilatation. In the 3 patients who underwent laser angioplasty alone, no noticeable improvement in distal blood flow was demonstrated by doppler velocimetry, and reocclusion occurred either soon afterwards (n = 2) or later (n = 1). Midterm results were much better in patients who had had additional balloon dilatation: early (3rd day) or late (2 months) reocclusion took place in only 3 patients. In the remaining 10 patients, followed up for periods of 1 week to 18 months (mean: 6 months), clinical improvement and recanalization were maintained.