Optimal long-term antithrombotic treatment of patients with stable coronary artery disease and atrial fibrillation: "OLTAT registry".

BACKGROUND: The optimal long-term antithrombotic treatment of patients with stable coronary artery disease (CAD) and atrial fibrillation (AF) is a challenge in daily practice. We sought to determine the prevalence of hemorrhagic complications and ischaemic events depending on antithrombotic strategy in patients with stable CAD and AF. METHODS: The primary outcome was major adverse cardiac and cerebrovascular events (MACCE) defined as a composite of cardiovascular mortality, myocardial infarction and ischaemic stroke. The subsequent risks of MACCE and clinically significant bleedings requiring hospitalisation (major safety outcome) were analyzed in a propensity score-matched analysis by adjusted Cox regression models. RESULTS: Six hundred and six patients with high thrombotic and bleeding risks (mean age 73.4 ±â€¯9.8 years, 25.2% female, CHA2DS2-VASc score:4.7 ±â€¯1.5, and HAS-BLED score:3.1 ±â€¯1.0) were included, and 127 propensity-matched pairs were analyzed. At inclusion, 172 patients (28.4%) were on oral anticoagulation (OAC) alone (75.6% on VKA and 24.4% on DOAC) and 434 patients (71.6%) on OAC + single antiplatelet therapy (SAPT) (71.9% on VKA and 28.1% on DOAC). At 5-year follow-up, MACCE rate did not significantly differ in both groups (30.9% in OAC + SAPT vs. 26.8% in OAC alone; adjusted HR 1.1 [0.8-1.5], p = 0.58), but clinically significant bleedings (28.3% vs. 18.5%; adjusted HR 1.8 [1.2-2.8], p = 0.005) and total deaths (29.5% vs. 20.8%; adjusted HR 1.4 [95% CI 1.0-2.2], p = 0.049) were higher in patients with OAC + SAPT than in patients with OAC alone. CONCLUSIONS: In patients with stable CAD and AF, the addition of antiplatelet therapy to VKA or DOAC therapy was independently associated with a higher risk of bleeding and overall mortality, without significant reduction in cardiac and cerebral ischaemic events.

[Cardiovascular involvement in Behçet's disease]. / Atteintes cardiovasculaires de la maladie de Behçet.

Vascular involvement is a common complication of Behçet's disease (BD) and affects up to 40% of BD patients. These complications worsen the prognosis of BD. The concept of vasculo-Behçet has been adopted for cases in which vascular complications dominate the clinical features. Vascular manifestations affect particularly young men, during the first years following onset of the disease. Venous complications are the most frequent vascular complications, affecting 14 to 40% of BD patients. Superficial and deep lower limb thrombosis is the most frequent venous complications but one third of venous thrombosis concern large vessels (such as cerebral venous thrombosis, pulmonary embolism, and inferior or superior vena cava, etc.). Budd-Chiari syndrome is the worst prognostic factor increasing mortality by 9 times. Arterial complications (2 to 17% of BD patients) include aneurysms and occlusions/stenosis. Main locations of arterial lesions are aortic (abdominal and thoracic), femoral, pulmonary and iliac arteries. Aneurysms are the most severe arterial complications, particularly pulmonary aneurysms associated with a high risk of massive bleeding. Cardiac complications (up to 6% of BD patients) include pericarditis, endocardial lesions (aortic regurgitation and less often mitral insufficiency), myocardial lesions (myocardial infarction, myocarditis and endomyocardial fibrosis) and intracardiac thrombosis (right ventricle and atrium). Coronary lesions complicated to myocardial infarction are the most severe cardiac complications. Treatment is based on corticosteroids and immunosuppressive drugs. The use of anticoagulation in venous thrombosis is still controversial.

[Current indications for cardiac MR imaging]. / Indications cliniques appropriées de l'IRM en pathologie cardio-vasculaire.

MRI has acquired over the years a role in the evaluation of cardiovascular pathology especially with regards to its ability to assess right and left ventricular function and delayed postcontrast "viability" sequences. Current class I clinical indications include: viability for patients with ischemic cardiomyopathy and acute coronary syndrome, etiology and prognostic evaluation of non-ischemic cardiomyopathies including myocarditis and arrhytmogenic right ventricular cardiomyopathy, chronic pericarditis and cardiac masses, non-urgent aortic aneurysm and dissection, congenital cardiopathies: vascular malformations and follow-up after curative or palliative surgery. MRI provides a complete non operator dependent evaluation, and is particularly useful for follow-up since it may be repeated due to its absence of ionizing radiation

[What's new on antithrombotics?]. / Que retenir de la littérature récente concernant les antithrombotiques ?

Management of venous thromboembolism disease could be improved by new drugs with lower risk of bleeding and without the need of regular monitoring of anticoagulant effect. In this way, idraparinux, anti-Xa inhibitor, has been compared to conventional therapy (coumarins) for the treatment of deep vein thrombosis and pulmonary embolism. Is it worth to treat patients more than six months? This has been evaluated in an interesting study. Prophylaxis after hip replacement surgery is indicated to reduce the risk of venous thromboembolism, new drugs are under investigation. Dabigatran etexilate, a direct thrombin inhibitor, has been shown as effective as enoxaparin in reducing the risk of venous thromboembolism after total hip replacement surgery. In 2007, new european guidelines for non-STsegment elevation acute coronary syndromes have been published. Two new antithrombotic drugs, bivalirudin and fondaparinux, are now part of the different possible choices according to specific considerations. New factor Xa and factor IIa inhibitors are under investigation and are compared to heparin in PCI for NSTE-ACS. Fondaparinux and more recently otamixaban have given interesting results. These new recommendations have not yet taken into account new data published in 2007. What will be the positioning of prasugrel, a new thienopyridine, after the results of theTRITON trial? In patients with SCA treated by PCI, prasugrel reduced the ischemic events, while increasing major bleedings. In 2007, numerous publications and meta-analyses on drug-eluting stents (DES) have been published and tempered the fear about a possible increase in mortality with the use of DES.

Characteristics and prognosis of patients with angiographic stent thrombosis: comparison between drug-eluting and bare-metal stents.

INTRODUCTION: Conflicting data exist on the risk of stent thrombosis with drug-eluting stents (DES) versus bare-metal stents (BMS). Little is known about the potential different characteristics and outcomes of DES versus BMS thrombosis. OBJECTIVE: To compare the characteristics, timing and outcomes of patients with angiographic stent thrombosis according to type of stent implanted. METHODS: The population comprised consecutive patients who underwent BMS or DES implantation (January 2003-April 2007) at Pitié-Salpêtrière Hospital. Data from patients with and without a stent thrombosis were compared to identify predictors of thrombosis. Timing of thrombosis (acute,<24 hours; subacute,<30 days; late,>30 days; very late,>1 year), clinical, angiographic and procedural characteristics, and outcomes were compared between patients with a BMS or DES thrombosis. RESULTS: A total of 3579 patients received a BMS (2815 lesions, 2318 patients) or a DES (1536 lesions, 1261 patients). Documented angiographic stent thrombosis occurred in 52 (1.4%) patients, 16 (1.3%) with a DES and 36 (1.6%) with a BMS. Rates of acute (0.1% versus 0.2%), subacute (1% versus 0.7%), late (both 0.2%) and very late (both 0.2%) thrombosis were similar in patients with BMS and DES thrombosis. Factors predictive of stent thrombosis were similar, including left ventricular failure (P<0.0001), initial percutaneous coronary intervention (PCI) for acute myocardial infarction (P<0.0001), multivessel PCI (P<0.0001), and balloon dilatation before stenting (P<0.04). Eleven (21%) cases of BMS (n=8, 22%) or DES (n=3, 19%) thrombosis arose soon after stopping antiplatelet therapy. Thirteen of 52 (25%) patients died a few hours after the event. Twenty-seven (52%) major adverse cardiac events occurred at 18 months, 7 in patients with a DES and 20 in those with a BMS (44% versus 55%, P=NS). These included 16 deaths (31%), 7 repeat PCIs and 4 myocardial infarctions. There were no independent predictive factors of death after stent thrombosis. CONCLUSIONS: BMS and DES thrombosis are similar in terms of timing of thrombosis, characteristics and outcomes, and share the same risk of late thrombosis after interruption of antiplatelet therapy.

Medium-term survival after primary angioplasty for myocardial infarction complicated by cardiogenic shock after the age of 75 years.

AIMS OF THE STUDY: To assess mortality in people > or =75 years of age 6 months after myocardial infarction complicated by cardiogenic shock and treated by angioplasty with complete revascularisation and optimal anti-thrombotic treatment; to compare results to those of younger patients with or without shock and to analyse predictive factors for death. MATERIALS AND METHODS: The study is based on 1011 consecutive patients with myocardial infarction admitted for primary angioplasty, subdivided into four groups by age and the presence or absence of cardiogenic shock: group 1 (<75 years of age without shock, n=733), group 2 (<75 years of age with shock, n=49), group 3 (> or =75 years of age without shock, n=208) and group 4 (> or =75 years of age with shock, n=20). These four patient groups were compared for mortality rates and predictive factors for in-hospital and 6 month mortality. RESULTS: In-hospital mortality in groups 1 to 4 was 1.7%, 30.6%, 9.1%, and 70% (p<0.0001) respectively and 6-month mortality was 3.1%, 40%, 16% and 78% (P<0.0001). By univariate analysis renal failure was a predictive factor for death at 6 months in patients without cardiogenic shock (groups 1 and 3), and left ventricular function in patients in group 2. No predictive factors were found in group 4 patients. The independent predictive factors for death at 6 months were: age >75 years of age (P<0.0003), cardiogenic shock (P<0.0001), triple vessel lesions (P<0.01) and creatinine clearance (P=0.004). CONCLUSION: Mortality after angioplasty remains high in people > or =75 years with cardiogenic shock despite all the advances in the management of myocardial infarction. These disappointing results should encourage us to assess the role of surgical revascularisation and circulatory assistance.

Serial magnetic resonance imaging correlates with neurological outcome in an experimental model of spinal cord ischemia.

BACKGROUND: Paraplegia complicating surgical thoracoabdominal aneurysm (TAA) repair remains an unpredictable and poorly understood phenomenon. The ability to identify patients at increased risk of delayed paraplegia before the process becomes irreversible could allow early interventions to attenuate this risk. METHODS: In a rabbit model of infra-renal spinal cord ischemia, serial T2 weighted (T2W) magnetic resonance (MR) imaging was performed 2- and 8 h after the ischemic insult with changes correlated with clinical outcome. Using the axial T2W images, signal intensity measurements of the lateral horns of the spinal cord were acquired, both above (that is, thoracolumbar cord) and below (that is, lumbar cord) the renal arteries. This ratio (lumbar/thoracolumbar cord signal intensity) was evaluated and compared between groups. RESULTS: No changes were seen in the signal intensity of rabbits that remained neurologically intact. Rabbits with delayed paralysis showed a significant (P<0.01) decrease in signal intensity ratio at 2 h (1.13+/-0.03), while a significant (P<0.01) increase was noted in those rabbits with immediate persistent paralysis (1.43+/-0.04). There was a significant (P<0.01) increase in the signal intensity ratios at 2 h in the delayed paralysis group (1.55+/-0.14), with a further significant (P<0.01) increase at 8 h in the immediate persistent paralysis group (1.76+/-0.07). CONCLUSIONS: Findings on MR imaging can differentiate clinical outcomes in this experimental model of spinal cord ischemia. While further studies are required, MR could be useful in predicting which patients are at risk for delayed paraplegia after TAA repair.

[The best of thrombosis in 2006]. / L'essentiel de 2006 en thrombose.

The year 2006 was an excellent year for trials publications on antithrombotic treatments. The results of several important trials were published. Firstly, two new antithrombotic molecules, fondaparinux (anti-Xa) and bivalirudine (anti-IIa), were the object of large scale trials, in coronary artery disease. Fondaparinux, in the OASIS-5 study, was compared with the reference treatment by enoxaparin. The efficacy was equivalent in the treatment of acute coronary syndromes without ST elevation, in the reduction of ischaemic events and, above all, was associated with a reduction in severe bleeding complications and reduced mortality at 9 days and 6 months. The ISAR-REACT 2 trial demonstrated the value of abciximab, a platelet membrane glycoprotein inhibitor, in the treatment of high risk acute coronary syndromes identified by the risk in troponin levels. The ACUITY trial showed that bivalirudine was as effective as abciximab in the treatment of acute coronary syndromes in terms of prevention of ischaemic events and that it reduced the number of bleeding complications. The CHARISMA trial looked at the possible benefit of biotherapy with clopidogrel and aspirin versus monotherapy with aspirin alone in a large panel of high cardiovascular risk patients. The globally negative results should, however, be closely analysed because some subgroups (symptomatic patients) were identified, in which a possible benefit was observed in contrast to other subgroups (multiple risk factors) in which biotherapy appeared to be deleterious. The results of other less publicised trials (STEEPLE, FIDO, ESPRIT) are also commented.

[The value of active stents for coronary angioplasty in patients with chronic renal failure]. / Intérêt du stent actif dans l'angioplastie coronaire chez l'insuffisant rénal chronique.

UNLABELLED: The risk of intra-stent restenosis has diminished considerably with the advent of endoprostheses which actively release sirolimus or paclitaxel. Patients with chronic renal failure constitute a high cardiovascular risk population, in whom the incidence of coronary heart disease is particularly high, representing one of the principal causes of death. The aim of this study, which included 152 patients, was to quantify the value of active stents for coronary angioplasty in patients with chronic renal failure. Thirty eight patients with chronic renal failure who underwent angioplasty with active stents were matched for age, sex and the presence of diabetes with 3 other groups of patients: one group with active stents but without renal failure, one group with inactive stents and no renal failure, and one group with inactive stents and chronic renal failure. The average follow up was 16 +/- 5 months. The acute stent thrombosis rate (2%) was not elevated in cases of renal failure nor after active stent implantation. Chronic renal failure significantly increased the mortality rate 16 months after angioplasty, whichever type of stent was used: 8 versus 2% deaths in patients with an inactive stent (p = 0.001). In renal failure, the risk of death was lower with an active stent (8 vs 26% with an inactive stent, p<0.05). Similarly, there was a non-significant trend towards a lower risk of death and/or infarction in renal failure after active stents (8 vs 21% with an inactive stent, NS). CONCLUSIONS: In this study, coronary angioplasty with an active stent in patients with chronic renal failure was associated with a lower mortality rate compared with inactive stents, with no increase in the risk of acute thrombosis.

[The best of thrombosis in 2005]. / L'essentiel de 2005 en thrombose.

The year 2005 was rich in new information. Many articles were published on antithrombotic therapy, the key stone in the management of several cardiovascular diseases which are the cardiologists' "daily bread". Antithrombotic treatment is essential in the treatment of patients undergoing interventional coronary procedures. The loading dose of 300 mg clopidogrel has been questioned. The ARMYDA-2 trial showed that a loading dose of 600 mg of clopidogrel administered 4 to 8 hours before coronary angioplasty significantly reduced the number of peri-procedural myocardial infarctions without increasing the risk of bleeding complications. Other molecules such as prasugrel could provide an alternative to treatment with clopidogrel. The results of a phase 2 trial (JUMBO-TIMI 26) comparing clopidogrel and prasugrel have opened the way for a large scale phase 3 trial which is currently under way. In myocardial infarction, the CLARITY-TIMI 28 trial showed that patients under 75 years of age with acute myocardial infarction of less than 12 hours duration treated with aspirin and thrombolytic therapy had better results with respect to the combined criteria of patency of the culprit artery and ischaemic complications with the addition of clopidogrel. In the CREATE trial, patients with acute myocardial infarction had a lower mortality and recurrence of infarction without significantly increasing the risk of stroke with reviparin. The development of ximelagatran has been held up by a potentially serious hepato-toxicity. Two large-scale trials were published this year, one in atrial fibrillation and the other in venous thrombosis. In the former, the hypothesis of non-inferiority compared with well conducted oral anticoagulation with coumadine was supported and, in the latter, the hypothesis of non-inferiority compared with treatment with enoxaparin followed by warfarin was also confirmed despite a higher number of coronary events in the xinelagatran group. Another study which merits a citation showed that in patients with a previous history of aspirin-induced bleeding ulcers, the association of low dose aspirin and a proton pump inhibitor was superior to the prescription of clopidogrel in the prevention of recurrent bleeding. A study of the pharmacogenetics of coumadine and the variability of its dosage was also a valuable contribution. In the field of management of bleeding, a study demonstrated the potential benefits of treatment with VIIa recombinant factor.

[The best of thrombosis in 2004]. / L'essentiel de 2004 en thrombose.

The optimal pharmacological antithrombotic treatment for interventional coronary procedures is a controversial subject. The ISAR-REACT trial investigated the necessity of a IIb/IIIa glycoprotein inhibitor in procedures not considered at high risk, that is to say excluding acute coronary syndromes, and concluded that there was no additional gain with this treatment compared with placebo when the patient was pre-treated with 600 mg of clopidogrel. The REPLACE-2 trial proposed an alternative to a treatment with NFH and IIb/IIIa glycoprotein inhibitor with the use of a direct antithrombin, bivalirudine. Heparin therapy of acute coronary syndromes and the eventual ensuing interventional coronary procedure may employ NFH or LMWH. New large scale trials (SYNERGY and phase A of the so-called A to Z trial) compared the two approaches and are reported later on. If facilitated angioplasty is a seductive concept, the best antithrombotic association remains to be determined (BRAVE trial). Bitherapy with a platelet inhibitor and an antithrombotic, ximegalatran, was tested in the ESTEEM trial and in the post-infarct period. Bitherapy with platelet inhibitors clopidogrel and aspirin versus clopidogrel alone was tested in patients with "ischaemic" stroke but does not seem to be more effective than monotherapy. In pulmonary embolism, the fondaparinux seems to be an alternative to NFH. Finally, the concept of resistance to platelet inhibitors is in vogue and is the subject of some interesting trials.

Cumulative adverse effects of diabetes mellitus and hypertension on coronary flow velocity reserve.

BACKGROUND: this study aimed to assess the hypothesis that essential hypertension (EH) may increase coronary microcirculation dysfunction in patients with type 2 diabetes mellitus (DM). Microvascular dysfunction has been reported in patients with DM or EH. Discordant results have been reported on cumulative adverse effects of the simultaneous presence of DM and EH on coronary flow velocity reserve (CFR). METHODS: CFR were compared in 13 hypertensive diabetics (group 1), 12 normotensive diabetics (group 2), 11 hypertensive non diabetics (group 3) and 29 normotensive non diabetic patients (group 4). CFR was calculated using an intracoronary Doppler-tipped flow wire. RESULTS: CFR was significantly lower in patients with both DM and EH (2.2 +/- 0.4 in group 1 vs 2.8 +/- 0.5, 2.8 +/- 0.6 and 2.9 +/- 0.7 in groups 2, 3 and 4 respectively, p<0.01). The presence of hypertension reduced CFR in diabetic patients with angiographically abnormal but unobstructed coronary arteries (2.1 +/- 0.3 in hypertensive vs 3.1 +/- 0.2 in normotensive diabetic patients, p<0.02). No cumulative adverse effect was observed in diabetics with angiographically normal coronary arteries (2.3 +/- 0.6 in hypertensive vs 2.6 +/- 0.5 in normotensive diabetic patients, NS). Multivariate analysis revealed that combination of DM and EH (p<0.007) was independently related to CFR. CONCLUSIONS: the presence of hypertension appears to worsen coronary microangiopathy in diabetic patients with unobstructed coronary artery disease. The cumulative effect of EH and DM on CFR impairment has consequences for decision-making during coronary angioplasty and could identify patients at risk for cardiomyopathy.

[Clopidogrel and thrombopenia. A case report]. / Clopidogrel et thrombopénie. A propos d'un cas.

We report our experience with a case of isolated profound thrombocytopenia after clopidogrel (thienopyridine) administration. No adverse event such as bleeding or thrombotic event had occurred, although clopidogrel has been discontinued two weeks after the coronary artery stenting. Despite the safety of clopidogrel, this case demonstrates that clopidogrel can be associated not only with thrombotic thrombocytopenic purpura but also with isolated thrombocytopenia.

Antistreptokinase platelet-activating antibodies are common and heterogeneous.

BACKGROUND: Platelet activation by antistreptokinase (SK) antibodies could impair the clinical effect of SK administration. OBJECTIVE: To better describe anti-SK antibodies with particular emphasis on procoagulant activities as a result of platelet activation. PATIENTS AND METHODS: Sera were collected from 146 patients with coronary artery disease: non-SK-treated, 95 from mainland France, 31 from French Polynesia; 20 patients from mainland in year 2 after SK treatment. Serum-induced SK-dependent platelet activation resulting in procoagulant activities was assessed with washed platelets from five donors representative of the known patterns of reactivities to IgG. RESULTS: Concentrations (2-5252 microg mL(-1)) and fibrinolytic neutralization titres (< 10 to > 1280) were found in the expected wide range and correlated (rho = 0.66, P < 0.0001). Platelet activation was detected with 145 samples, but varied in intensity and pattern (depending on the donors), although there was no systematic hierarchy; it was presumably due to IgG (inhibited by an IgG Fc receptor-blocking antibody and recovered in the IgG fraction) and only partially affected by aspirin. Marked platelet activation could be detected in samples with concentration as low as 2 microg mL(-1), and/or no detectable neutralizing titers. The way of immunization to SK was not found to influence the functional profile of antibodies. CONCLUSION: Anti-SK platelet-activating antibodies are widespread, heterogeneous, poorly predictable on the basis of their antifibrinolytic effect and strong enough to trigger procoagulant activities. Their clinical relevance should be formally assessed, using patients' own platelets for detection owing to the variation of platelet reactivity.

Myocardial viability, coronary flow reserve, and in-hospital predictors of late recovery of contractility following successful primary stenting for acute myocardial infarction.

OBJECTIVE: To assess the relation between myocardial viability, coronary flow reserve, and recovery of myocardial contractility after stenting for acute myocardial infarction. DESIGN: Consecutive sample prospective study. SETTING: University hospital. PATIENTS: 41 patients with single vessel disease and successful primary stenting for a first acute myocardial infarction. INTERVENTIONS: (201)Tl single photon emission computed tomography, contrast ventriculography, and intracoronary Doppler performed 7 (1) days after primary stenting. MAIN OUTCOME MEASURES: Regional contractility recovery assessed by contrast ventriculography at 6 (1) months' follow up. RESULTS: On univariate analysis, contractility recovery was correlated to prereperfusion anterograde and collateral flow grades (r = 0.41, p = 0.03 and r = 0.55, p = 0.0004), viability index (r = 0.55, p = 0.04), peak creatine kinase concentrations (r = -0.55, p = 0.0005), left ventricular ejection fraction (r = 0.45, p = 0.005), end diastolic pressure (r = -0.62, p < 0.0001), end systolic volume index (r = -0.47, p = 0.01), and the extent of hypokinetic area (r = -0.48, p = 0.003), but not the coronary flow reserve. On multivariate analysis, independent predictors of late contractility recovery were prereperfusion anterograde and collateral flow grades and viability index. Relative coronary flow reserve, reflecting the culprit vessel's microvascular function, was correlated only to the extent of the infarct risk area (r = -0.45, p = 0.003). CONCLUSIONS: Independent predictors of contractility recovery between the seventh day and the sixth month after successful stenting for acute myocardial infarction are prereperfusion anterograde and collateral flows and myocardial viability. The culprit vessel's microvascular dysfunction is independent of myocardial viability and contractility and correlated to the extent of "jeopardised microvasculature".

[Absence of nephro-protective effect of acetylcysteine in patients with chronic renal failure investigated by coronary angiography]. / Absence d'effet néphroprotecteur de l'acetylcystéine chez les patients avec insuffisance rénale chronique explorés par coronarographie.

Recent studies have suggested that an oral dose of acetylcysteine could play a prophylactic role in the prevention of nephrotoxicity from iodine contrast media in patients affected by chronic renal failure. Between June 2001 and September 2002 we selected 120 patients with a basal plasma creatinine level greater than 1.36 mg/dl investigated by coronary angiography. The treatment group included 60 patients who received 600 mg of acetylcysteine in the morning and evening before the day of the examination together with intravenous saline hydration. The control group patients received hydration alone. The clinical characteristics of the groups were comparable as well as the basal plasma creatinine level: 2.01+/-1.1 mg/dl in the acetylcysteine group and 1.81+/-0.69 in the control group. The plasma creatinine level was measured 24 and 48 hours after coronary angiography. The respective changes in plasma creatinine level at 24 and 48 hours were 0.12+/-0.29 and 0.02+/-0.29 mg/dl in the acetylcysteine group and 0.06+/-0.29 and 0.07+/-0.43 mg/dl in the control group (NS). Acute renal failure caused by the contrast medium, defined by an increase of 25% in the plasma creatinine level compared to the basal value, occurred in 3 patients from the acetylcysteine group and 2 patients from the control group. The only predictive factor for acute renal failure was the quantity of contrast medium (316+/-141 vs 173+/-115 ml, p<0.05). In conclusion, acute renal failure caused by contrast medium is rare in sufficiently hydrated patients with moderate chronic renal failure when a low dose of contrast medium is used. Our study does not confirm a prophylactic effect of acetylcysteine in the prevention of nephrotoxicity from contrast media following coronary angiography in patients with moderate chronic renal failure.

[Value of combined coronary angioplasty and coronary angiography]. / Intérêt de l'angioplastie coronaire dans le même temps que la coronarographie.

Combined coronary angioplasty and coronary angiography is performed in most catheter laboratories and has become a routine procedure. The aim of this study was to assess its clinical results and economic value. This was a retrospective monocenter study performed over an 11 year period (1990-2000) which included 2,727 patients requiring coronary angioplasty after coronary angiography. The angioplasty procedure was performed at the same time as angiography (combined, n = 1,809) or after angiography (deferred, n = 631). Patients admitted for acute coronary syndromes not stabilised by pharmacological interventions were excluded from the study. The comparison of these two modes of angioplasty was based on primary success rates, complications, duration of hospital stay and hospital costs. The combined procedure was used progressively more frequently over the study period, increasing from 54% to 88% in 2000. The hospital clinical results (Success and complication rates) were comparable in the two groups. The predictive factors of failure were the year of the angioplasty procedure and occlusive lesions on multivariate analysis. The combined procedure was associated with a shorter hospital stay than deferred angioplasty (8.2 +/- 6.1 days versus 15.0 +/- 8.0 days, p = 0.0001) and with lower costs. The authors conclude that combined coronary angiography-angioplasty is as effective and as safe as deferred angioplasty. It is associated with a shorter hospital stay and lower hospital costs.

[Mediastinal tumor revealed by myocardial infarction]. / Tumeur médiastinale révélée par un infarctus du myocarde.

We report the case of a patient with a past history of coronary atherosclerosis treated with primary angioplasty 5 hours following an inferior myocardial infarction. Echocardiography performed during the procedure revealed a mediastinal tumour invading the tricuspid, responsible for the occlusion of the right coronary. Infarction due to tumour compression is a rare presentation of mediastinal tumour. Diagnosis relies on echocardiographic, CT or magnetic resonance imaging. The prognosis is linked to the tumour pathology.