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Several hyperthyroidism misdiagnoses cases have been recently described due to biotin intake. Biotin used in immuno-analysis assays which rely on biotin/streptavidin binding properties. In these assays, high plasmatic biotin levels can lead to major analytical interferences resulting in falsely higher (competition tests) or falsely reduced determinations (for sandwiches assays). We performed a simulation test of biotin intake with patient's samples. We studied the effect of biotin on cardiac troponin I and total vitamin D (D 2 +D 3 ) assays that are using biotin-streptavidin binding on Dimension EXL®. Increasing doses of biotin were added (28 samples for each parameter) before the assays. The results evidenced a significant negative interference of biotin on cardiac troponin I determinations for concentrations of 100 ng/mL and above, with a total loss of signal for higher biotin additions. Such interference may lead to inappropriate therapeutic decisions. Positive interferences were observed on total vitamin D (D 2 +D 3 ) with less impact for therapeutic decisions.

To cope with overcrowding, a consequence of their constant growth, emergency departments have implemented operational strategies based on triage systems. Despite its interest, nurse triage has been limited by several hindrances, and new strategies are emerging. Among those, advanced nurse triage, allowing a nurse to initiate the diagnostic process just after categorization of the patient, seems to be promising. A study on advanced nurse triage for patients presenting with chest pain has been conducted in the emergency department of the CHU of Liège. The encouraging results obtained following this new system demonstrate a reduction of the delay to management of patients, and a reduction of the total length of stay in the emergency unit mainly during overcrowding periods. Advanced nurse triage, in addition to a conventional triage during overcrowding periods, improves management of patients in terms of time and reduces the total time spent in the emergency department.

Screening of myocardial ischemia refers to the use of one or more diagnostic tests for coronary heart disease with a dual objective of appropriateness and promptness. In women, as compared to men, the accuracy of the different tests is worse. Thus, to overcome this sex-related penalty, we must define a diagnosis strategy based on risk stratification, enabling the identification of patients requiring invasive investigations. This review discusses various non-invasive diagnostic tests focusing on a female-specific approach and defines the use of numerous diagnostic tests with respect to both risk stratification and symptoms., (Copyright © 2016. Published by Elsevier SAS.)

Many differences have been reported regarding gender in angioplasty procedures (PCI), but their potential influence on clinical outcomes after CTO PCI has not been elucidated. Aim of this paper is to analyse these potential differences starting from 2 clinical cases. The basic features found in the two clinical cases presented here, older age and presence of diabetes (that are more frequent in women), are in line with the differences identified in non-CTO studies on angioplasty. Furthermore, CTO in women are generally under-diagnosed and less frequently treated by angioplasty than in men. These features combined to the often atypical clinical presentation could explain why women are generally less frequently enrolled in CTO registries than men. Although data on the impact of gender on this topic are scarce, it appears that, despite a clear outcome difference in patients who have a successful CTO angioplasty and similar success rates, women are still under-referred for a CTO angioplasty. Indeed, CTO angioplasty seems a valid therapeutic option, in women as in men., (Copyright © 2016 Elsevier Masson SAS. All rights reserved.)

Coronary artery disease is the most frequent heart disease in our population. Its pathogenesis is well known and the first manifestation of the disease can occur in young adults. The main cause is atherosclerosis. The prevention and treatment of cardiovascular risk factors are key elements. The clinician's diagnosis is crucial before coronary arteriography, since the rate of percutaneous procedures decreases with the gravity of the starting diagnosis.

Introduction: Abnormal albuminuria (≥ 30 mg/g) and low estimated glomerular filtration rate (eGFR<60 mL/min/1.73 m(2)) not only are renal risk factors, but also cardiovascular and coronarian risk factors. Though, the relation between coronary risk and renal risk, and its interaction with insufficiently controlled brachial pressure (BP) is poorly described in the literature., Subjects and Methods: We realised a cross-sectional study on subjects 40 and older, having attended a medical exam in 11 IRSA centers between 2006 and 2010. Every subject filled a questionnaire, underwent biological analysis, and a clinical examination. eGFR and albuminuria were measured, and the 10-year risk of coronarian event was calculated (Laurier's equation), Results: We analysed 118,314 subjects, amongst whom 96,400 had no personal cardiovascular history. Amongst those, 9.1% had a 10-year coronary risk over 10%. There was a continuous relationship between coronary risk and renal risk: subjects with a risk above 15% had a significative risk of pathological albuminuria (OR: 6.87 [5.58-8.44]), and of low eGFR (2.26 [1.82-2.78]) compared to those with a risk under 5%. There was a continuous relationship between BP and renal risk, with a significative risk of pathological albuminuria (OR=7.75 [6.69-8.96]) and of low eGFR (OR: 1.33 [1.09-1.60]) in subjects with BP greater than or equal to 180/110 mmHg, compared to those with normal BP., Conclusion: In the French population, 9.1% of subjects have a 10-year coronary risk above 10%. This risk is associated to abnormalities of the renal function. The relation between coronary risk and renal risk is continuous and dose-dependent, as is the relation between BP and renal risk., (Copyright © 2013 Elsevier Masson SAS. All rights reserved.)

Prevention of coronary heart disease is a priority for cardiovascular prevention, as coronary deaths account for half of all cardiovascular deaths. About 20% of coronary events occur in high-risk but asymptomatic and apparently healthy subjects. Such patients can be identified by using a novel two-step strategy to evaluate the coronary risk. The first step is obligatory and is based on simple calculation of a multifactorial risk score derived from the Framingham study and integrating all traditional cardiovascular risk factors. The Framingham risk score can be used to estimate the 10-year probability of fatal and non-fatal coronary heart disease and to identify subjects at high coronary risk (probability greater than 20%). The second step is optional and mainly concerns subjects with Framingham scores between 10% and 20% (intermediate risk). A substantial proportion of these subjects are incorrectly classified by the Framingham score and are in fact at high risk. Risk requalification is based mainly on non-invasive imaging of preclinical atherosclerosis in extracranial carotid arteries (ultrasound-assessed plaque) or in coronary arteries (no-contrast CT assessment of coronary calcium). This novel strategy for coronary risk evaluation could help to maintain and improve the ongoing regression of cardiovascular mortality, especially in women and elderly people.

Objective: Coronary artery disease (CAD) is a complex multifactorial disease due to the interaction of multiple genes variations and environmental factors. Genetic variants of lipoprotein lipase (LPL), a key enzyme in the hydrolysis of triglyceride rich particles, may contribute to CAD. We analysed here the frequency of LPL variants (p.Asp9Asn, p.Asn291Ser and p.Ser447X) in a Tunisian population as well as their association with circulating lipid level and risk of CAD., Patients and Methods: LPL variations were investigated by PCR-RFLP and lipid parameters were measured in 135 patients and 109 controls., Results: The frequency of the p.Asp9Asn variation was 10.37% in CAD patients versus 3.66% in controls. The frequency for the p.Ser447X variation was 8.8% in CAD patients versus 13.7% in controls. There was no significant association between these two variants and CAD. The p.Asn291Ser mutation variation was absent in this population. In healthy subjects, heterozygote carriers of the p.Asp9Asn substitution had a significant increase level of total cholesterol (4.2±0.9mmol/L vs 5.6±1.2mmol/L; P=0.01) and a decreased level of HDL-cholesterol (1.36±0.3mmol/L vs 0.93±0.1mmol/L; P=0.045)., Conclusion: There was no significant association between genetic variants of the LPL gene and CAD in this Tunisian population. The very low frequency of the p.Asn291Ser variation may be an ethnic specificity of Tunisians., (Copyright © 2011 Elsevier Masson SAS. All rights reserved.)

Of all cardiovascular deaths, those from coronary origin are preponderant. Therefore the reduction of cardiovascular mortality requires improving substantially coronary prevention. Three categories of coronary risk (probability of hard coronary event at 10 years; low <10%, intermediate 10 to 20%, high > 20%) are identifiable via scoring procedure integrating multiple traditional risk factors. Risk is also high, independent of score value, in the case of coexisting major risk factor (diabetes, severe hypertension or hypercholesterolemia) and/or clinically overt coronary, peripheral or cerebral vascular disease. The knowledge of the distribution of coronary risk categories within the population allows defining preventives strategies and estimating needs and costs. Such distribution is pyramidal with the majority of the population at low or intermediate risk while only 15% at high risk. Although largely in minority, the latter convey an important proportion of coronary accidents so justifying the priority given to detection and intensive treatment of high coronary risk condition.

Sleep-disordered breathing may take the form of apnoea or hypopnoea. These conditions have physiological consequences on the cardiovascular function. Night staff in cardiac rehabilitation departments must therefore be able to organise themselves to screen for risks of sleep-disordered breathing, with collaboration between medical and paramedical staff.

Whilst optimal management of acute coronary syndromes and, in particular, the value of an early invasive strategy including revascularization, is well defined, the treatment of asymptomatic and stable coronary artery disease (CAD) has been more empirical. Recent studies clarify the benefits of different strategies. Strict control of cardiovascular risk factors (CVRF), with pharmacological intervention if necessary, remains the cornerstone of CAD management. Systematic screening of asymptomatic patients, even in categories such as those with diabetes, is not recommended. Furthermore, initial revascularization in patients with stable coronary heart disease, and no high risk lesions or disabling angina, has no benefit over medical management of CVRF.

The recent ACCORD and DIAD studies revealed results which could modify treatments and the screening of diabetes vascular complications. Indeed, ACCORD shows no benefit on the prevention of diabetes vascular complications by aggressive treatment of hypertension or the combined treatment of the dyslipidemia. The intensive treatment of the blood glucose, if associated with severe hypoglycemias, increases mortality. DIAD revealed 20% of silent myocardial ischaemia in diabetic patients but no beneficial effect on the cardiovascular mortality. A careful reading of these studies in the light of long term studies such as UKPDS and STENO reveals that these negative results are generated by a too short follow-up and too aggressive objectives. The long term studies reveal that more realistic objectives remain beneficial.

The severity of depression is related to its clinical features and also its impact in terms of morbidity and mortality. Depression is the most common psychiatric disorders associated with suicide and is found in almost one out of two cases, in 85% of situations associated with another mental disorder. Clinically severe depression also has a 4 to 5 times higher long term risk of suicide than mild or moderate depression. Severe depression is also associated with significantly increased deaths from natural causes : in absolute terms this is similar to the additional mortality rate from suicide. Cardiovascular diseases, particularly coronary, are a particular feature of this increased cause of natural deaths. These findings justify the development of prevention and screening for these diseases in depressed patients., (Copyright 2009 L'Encéphale. Published by Elsevier Masson SAS.. All rights reserved.)

Due to technical advances, multidetector computed tomography (MDCT) allows evaluation of the coronary arteries and could in specific clinical indications provide a minimally invasive alternative to coronary angiography (CA). Recent technical advances combined with the availability of 64 row MDCT have significantly improved the evaluation of the native coronary arteries. However limitations remain for the evaluation of bypass grafts and stents. In this paper, we present a review the current literature on the diagnostic accuracy of 64 row MDCT in the assessment of coronary artery disease, and discuss the clinical implications and proposed indications of coronary CTA.

Magnetic resonance imaging (MRI) has become a useful, even essential, examination in recent years, for the exploration of patients with coronary disease. MRI has several different roles, even though it remains insufficiently requested because insufficiently available. Today it is the reference examination for assessing indicators of ventricular function (volume, ejection fraction, ventricular mass); their prognostic value and importance in determining treatment are well recognized. In the postinfarction period, MRI using late enhancement techniques allows a precise analysis of the extent of necrosis, in terms of segments and transmural involvement. MRI is indicated, especially preoperatively, in cases of ventricular remodeling and its consequences (functional impairment, aneurysms, parietal thrombus). MRI with pharmacological stress may also be used as a tool for detecting myocardial ischemia; in this case, perfusion or first-pass sequences should be used. On the other hand, cardiac MRI for morphologic exploration of the coronary network and measurement of stenosis is not yet routine.

The slow progression over decades of coronary atheroma is often compensated for by arterial remodeling and collateral circulation. Coronary artery disease is therefore often asymptomatic. Sudden rupture of unstable atheromatous plaque always leads to endocoronary thrombus formation. The magnitude and the time frame of this endovascular thrombotic process determine the severity of its clinical consequences: no symptoms, exercise angina, unstable angina, acute transmural myocardial infarction, or sudden death. Two amply validated treatments have the potential to decrease both the probability and the severity of plaque rupture: statins and platelet inhibitors, which are both indicated in all cases of coronary disease. The other therapeutic tools - anti-ischemic drugs, ACE inhibitors, angioplasty, and coronary bypass - are widely used in the management of coronary disease, but their indications should be tailored to each individual clinical situation.

Background: Non cardiac chest pain is a frequent symptom in general population. Gastroesophageal reflux disease is the first cause of chest pain without cardiac etiology., Aim: This review aimed to determine the specific mechanisms for esophageal-induced chest pain, to evaluate the results of the available methods of diagnosis, and to precise the therapeutic options in these patients., Methods: Literature Review, Results: Gastroesophageal reflux disease is the most frequent etiology of "DTPA".The mechanism of pathogeny is complex. After eliminating coronary disease, diagnosis is based on esophagus ph-metry and markers. Therapeutic test with PPI would be an alternative option to ph-metry. Treatment is based on PPI with appropriate dose and duration. Surgical treatment is indicated only for selected patients.

Background: Cholesterol crystal embolism (CCE) is a rare disorder which can complicate cardiac catheterization, angiographic studies and cardiovascular surgery. The CCE exposes to a great risk of renal failure and it can even threaten life by means of a multi visceral failing syndrome., Aim: Report a new case of CCE following cardiac catheterization., Case: We report the observation of a 63-year-old patient who had a coronary angiography via the right femoral artery after a myocardial infarction. This examination has showed a multi-vessel coronary disease. 15 days later, the patient presented purplish and painful discoloration of his toes. The laboratory findings showed a mild inflammatory syndrome and eosinophilia at 700 / microL. There was not a renal dysfunction nor proteinuria nor hematuria. We performed a skin biopsy and made the diagnosis of CCE. Trans oesophageal echography objectified an irregular atherosclerotic plaque in the isthmic aorta. The CT scan revealed a spindle-shaped aneurysm in the end of the abdominal aorta. This aneurysm contains a marginal surrounding thrombosis with high embolic risk. The patient was put under clopidogrel, enoxaparin, simvastatin, colchicine and atenolol and operated successfully., Conclusion: The two particularities of this observation are, on one hand, the absence of a renal involvement, which represents the main prognostic factor of the CCE. On the other hand, the CCE has revealed a very unstable aneurysm of the aorta which could be complicated during the cardiac catheterisation. The CCE is a difficult diagnosis that must be remembered before any cardiac catheterisation, because it often reflects unstable aortic atherosclerotic lesions.

Churg-Strauss syndrome and Wegener granulomatosis are the two principal ANCA-associated vasculitides. Cardiac damage is frequent and prognosis poor. This damage is often subclinical initially and undetectable with standard cardiac imaging techniques (such as cardiac ultrasound or myocardial scintigraphy). Cardiac MRI permits early diagnosis of the different types of cardiac damage (myocarditis, pericarditis, and impaired myocardiac perfusion) that may occur during ANCA-associated vasculitis, even before the onset of symptoms. Early detection of this cardiac damage is crucial for it enables faster implementation of aggressive treatment, which may significantly improve disease prognosis. The widespread, even routine, practice of cardiac MRI in patients with ANCA-associated vasculitis thus seems justified, for this noninvasive examination provides essential diagnostic and prognostic information and helps guide therapeutic management.

The aim of the study was to evaluate the incidence of asymptomatic coronary heart disease in patients with cardiovascular risk factors and evaluate the diagnostic value of myocardial stress perfusion magnetic resonance as screening test in these patients. We performed a retrospective analysis of 103 consecutive asymptomatic patients with at least one clinical risk factor for cardiovascular disease, who have undergone myocardial stress perfusion magnetic resonance. For respective evaluation of ischemic myocardium and infracted myocardium, magnetic resonance imaging protocol included the study of both myocardial viability by late enhancement imaging and first-pass perfusion at rest and during maximal stress (adenosine). The reference standard was catheter coronary angiography for 10 patients and clinical follow-up for 93 patients. The incidence of coronary heart disease was 22/103 (21%), including 6/103 (6%) ischemia and 16/103 (15%) infarcts. Respective sensitivity, specificity, negative and positive predictive values for myocardial stress perfusion magnetic resonance in detecting ischemic myocardium were 100, 97, 67 and 100%. Myocardial stress perfusion magnetic resonance can be regarded and further investigated as screening test for the detection of asymptomatic coronary heart disease in high-risk subjects. Prospective studies, larger study groups and cost-effectiveness analysis are needed.

Until recently, for many people dying from a myocardial infarction was an inevitable fate. Myocardial infarction mortality rates have decreased drastically. At the same time, stents have clearly secured coronary angioplasties, removing the problems linked to coronary dissections such as abrupt closure or emergency coronary bypass. The iatrogenic risks have increased on account of the use of sophisticated techniques, powerful medications or the treatment of older patients. On the one hand, the media have informed people about the tremendous improvements in cardiology, however, on the other hand they have also given them over-optimistic expectations leading to an increase in the number of physicians sued. Now, physicians have to master ever more complex parameters such as new examination techniques prescriptions and interpretation (CT-scanner, MRI) and new medications. In order to prevent lawsuits, physicians should educate and inform their patients. To increase their chances in case of a lawsuit, physicians should improve the traceability of the treatment prescribed and information given to patients, but also make patients assume their responsibilities when they are reluctant to follow medical advices or treatments.

Background: Since 1985, two sources of information currently yield coronary disease frequency indicators among the French population: the national cause of death statistics set up by the CépiDC (INSERM), on the one hand, and three registries recording myocardial infarction and coronary deaths as defined by the WHO MONICA Project in three regions (Bas-Rhin, Communauté Urbaine de Lille, Haute-Garonne) on the other hand. Particularly, an inquiry for each possibly coronary death allows the registries to conclude positively (with or without a myocardial infarction), negatively or that no conclusion can be drawn because of insufficient data. The aim of the present work is to analyze concordance between coronary deaths issuing from the two sources according to their definition, while taking into account, or not, multiple causes listed on the death certificates., Material: and methods: In total, 4,664 deaths occurring in 2000 in the 35-64 year-old population of the three regions identified by the CépiDc were paired with the 812 deaths analyzed by the registries. The MONICA classification was compared with that of the CépiDC which used the ICD 10th Revision of the initial cause or after taking into account multiple causes. In each case, the concordance between the final classifications (coronary deaths or not) and the mortality ratio obtained from the two sources were computed., Results: and conclusions: Eight hundred and six deaths could be paired: 310 with a coronary cause according to the registries, 420 of presumed coronary cause but with insufficient data and 76 of non coronary origin. Whereas the total number of coronary deaths was similar for the two sources, their concordance was relatively low (kappa=0.61). However, when the deaths with insufficient data were included in the MONICA definition, concordance decreased and a large underestimation (59%) of the coronary mortality is given by the national statistics as compared to the registries. Taking into account multiple causes of death and not only the initial cause permitted partly to reduce this underestimation (42%) and to increase concordance (kappa from 0.46 to 0.51). These findings have important consequences for international comparisons concerning coronary disease. Indeed, the MONICA Project showed that the frequency of deaths with insufficient data was especially elevated in France leading to an underestimation of the coronary death rates provided by the national statistics in comparison with other countries, particularly in Europe.

Diabetes represents as independent risk factor for coronary artery disease (CAD) and the prognosis in term of survival rates is worse for diabetic patients who have CAD with report to those with CAD but no diabetes. The coronary artery disease in diabetes has specificities and, in particular, more extensive atherosclerosis. Diabetic patients are also more frequently asymptomatic. Due to the extreme complexity of ischemic vascular disease in patients with diabetes, an optimal therapeutic strategy is based on the correction of elevated blood glucose and lipid levels, of blood pressure, of platelet and coagulation abnormalities. Diabetic patients benefit from secondary prevention by drug therapy(aspirin, lipid lowering with statines, beta blocker and ACE inhibitors) to the same extent as, or more than, non-diabetic patients. Both percutaneous and surgical myocardial revascularization have been proved equally effective for CAD treatment in diabetes. A recent randomized trial has shown a significantly improved outcome after surgical revascularization. But, the effects of drug-eluting stents, which dramatically decrease the incidence of re-stenosis, seem promising.

NEW DENOMINATIONS: With the arrival of new therapeutic strategies requiring rapid intervention, acute coronary syndromes required classification on earlier data than the Q-wave or MB creatinine kinase. In a patient with anginal pain and depending on the electrocardiogram, we now distinguish syndromes with or without ST segment elevation. REGARDING ANTIPLATELET DRUGS: Aspirin is used in all cases, as well as clopidogrel. Anti PG IIb-IIIa agents are set aside only for the forms at risk, when an angioplasty is envisaged in the short term. ANTICOAGULANTS: Enoxaparin has demonstrated its superiority over unfractionated heparin. In general, the biological controls are not indispensables; they can however be used in certain cases (notably elderly patients). OTHER TREATMENTS: These are beta-blockers (first dose via the intravenous route in the case of persisting pain, then relay to the oral route), calcium-channel blockers (diltiazem, verapamil) when beta-blockers are contraindicated, nitrate derivatives with demonstrated antalgic effect but not to be used if an extension to the right ventricle or low blood pressure is suspected, nasal oxygen in the case of cyanosis or respiratory distress, enzyme conversion inhibitors if hypertension persists, and repeated intravenous injections of morphine in the case of persisting intense pain. CORONARY REVASCULARISATION: In all the patients considered at high risk, coronary revascularisation is recommended within the first 24 hours, when technically possible.

UNBLOCK THE CORONARY ARTERIES: For the treatment of acute coronary syndromes with ST-segment elevation, emergency repermeabilisation is of the artery is crucial, generally by primary angioplasty than by fibrinolysis. The other treatments have little beneficial effects on mortality. Primary angioplasty is the technique of choice when it can be performed in the intensive care units with staff with sufficient experience and within the 90 minutes following the preliminary medical management, and benefiting from the supply of PG IIb-IIIa. THROMBOLYSIS: Performed before the twelfth hour, thrombolysis reduces mortality. The earlier it is performed the greater the benefits. A significant reduction is mortality is observed even in patients aged over 75. The indications for coronography are determined by the existence of clinical risk factors and by the data of supplementary non-invasive examinations (sonography, scintigraphy, effort testing). When clinical risk factors exist from the start, a coronography must be performed. In the absence of initial risks, and if the non-invasive examination reveals risk factors, then a coronarography should be performed.

Purpose: To define a subgroup of patients at increased risk of renal artery stenosis (RAS) in a population of patients undergoing cardiac catheterization., Materials and Methods: A total of 467 patients (mean age of 64 Years +/-11) underwent cardiac catheterization and aortography Results were evaluated to detect correlations between the presence or absence of RAS and clinical and biological parameters., Results: A total of 42 (9%) patients had a renal artery stenosis. Univariate analysis defined parameters correlated with the presence of RAS: systolic blood pressure (p=0.03), pulse pressure (p=0.005), age (p<0.0001), creatinine clearance (p<0.0001), 2-vessel (p=0.028) and 3-vessel (p=0.037) coronary artery diseases. Multivariate analysis showed that the presence of RAS correlated to creatinine clearance (p=0.02) and 2-vessel coronary artery disease. A creatinine clearance between 30 and 60 ml/min and multi-vessel coronary artery disease defined a subgroup at increased risk of RAS with sensitivity, specificity, positive and negative predictive values of: 47.6, 90.1, 32.3 and 94.6%. The prevalence of renal artery stenosis was 5.2% when both parameters were absent., Conclusion: Patients with mild renal insufficiency and multi-vessel coronary artery disease defined a subgroup of patients at increased risk of RAS (32.5%) that may benefit from abdominal aortography performed at the time of cardiac catheterization.

The authors report their own experience and a review of the current literature in the field of cardiac MR (CMR). Latest technical improvements now allow obtaining both anatomical and functional imaging of the beating heart and great vessels in most pathological conditions. Established CMR indications such as cardiac tumors, pericardial diseases, operated congenital heart diseases, valvular diseases, arythmogenic right ventricular dysplasia, specific cardiomyopathies and great vessels of the thorax are reviewed and updated. Current applications in post myocardial infarction such as perfusion and viability imaging sequences are described. Moreover, CMR applications in syndrome X and myocarditis are evoked. Medical contra-indications and technical limitations of CMR are also discussed. Finally, the authors insist on the interest of a real partnership between radiologists and cardiologists for these procedures.

There are two types of acute coronary syndromes : those with or without ST-segment elevation. The former require urgent therapeutic measures to reopen the culprit artery (intravenous thrombolysis or primary percutaneous coronary intervention). For the latter, risk stratification is essential and is based upon clinical and biochemical markers. Among them, recent and repeated anginal attacks, ST-segment modifications on admission electrocardiogram, and increased markers of myonecrosis (particularly increased troponin levels) are strong predictors of untoward outcome. According to the risk profile, the initial management is based upon an invasive strategy with powerful antithrombotic medications and urgent angiography, or upon a non-invasive strategy using stress testing, preferably coupled with myocardial imaging techniques. In all instances, secondary prevention measures are determinant to try and stop the progression of the atherosclerotic disease.

In 2003, risk stratification in coronary heart disease is routinely performed by the results of coronary angiogram, the invasive gold standard angiography. Combined with the left ventricular ejection fraction assessment, the classification in one, two or three vessel disease remain the cornerstone of the revascularization strategy despite well-known limitations of this approach. Invasive coronary angiography is a mature technic with recommendations for training program and guidelines for indications. By comparison, the new noninvasive coronary imaging tools, computed tomography (CT) and magnetic resonance (MR) imaging, are just emerging. Coronary artery MR angiography is one of the most challenging areas because of the size and topology of the coronary arteries, as well as cardiac and respiratory motion. Multidetector-row and multisclice spiral computed tomography appear of most value for the detection of coronary artery disease with an excellent negative predictive value for proximal and middle main branches. Together, MR and CT, provide unique information that may predict cardiovascular risk. They identify flow-limiting coronary stenoses and calcified plaques, directly image the atherosclerotic lesions, measure atherosclerotic burden and characterize plaque components. Nevertheless, invasive coronary angiography still remain the first step of percutaneous coronary intervention. Therefore, one of the ultimate goals for the clinicians is the identification of the high-risk patient through a combination of strategies such as assessment of conventional risk factors, blood markers, and imaging. Indifferently to the imaging tool, the treatment should consider a human being and not only a picture.

Slice Imaging technology progress allows a good approach of coronary arteries. MRI and Multislice Computed Tomography (MSCT) are in competition. Inspite of important progress, MRI of coronary artery disease remains "disappointing". With this imaging technology, there is a good plaque burden and myocardium visualisation. MST, and particularly with 16 slice technology, allows a good coronary stenosis identification. This technology enables soft plaque and myocardial ischemia detection. It is now possible to detect coronary heart disease with MSCT, which can replace or help a coronary angiogram in some indications.

The aim of the OSCAR observatory was to describe the medical management of patients hospitalised for acute coronary syndrome (ACS). Demographic characteristics, risk factors, history of cardiovascular events, diagnostic and therapeutic procedures on admission and during the stay in hospital were recorded. From september 2000 to february 2001, 869 patients with acute coronary syndrome were enrolled in this survey. This sample of patients is quite similar to the one usually described in such studies with a male/female ratio of 2.7 and a mean age of 66. The initial diagnosis at entry was: 23.6% patients with unstable angina, 34.4% patients with myocardial infarction with ST elevation, and 42.0% of patients with myocardial infarction without ST-elevation. Troponins were used in 65% patients for troponin I, 13% for troponin T and should be more widely used. Whatever the inclusion diagnosis, planned procedures or biological data, only 25% of hospitalized patients for acute coronary syndrome were treated with anti-GPIIb/IIIa. This rate of treatment was lower than expected by the guidelines published by Societies of cardiology.

The diagnosis of unstable angina (troponine undetectable) is often difficult in the absence of electrocardiographic changes after suggestive chest pains. The object of this study was to analyse the kinetics of Brain Natiuretic Peptide (BNP) during acute coronary syndromes (ACS) without ST elevation. Plasma BNP was measured every 6 hours for 48 hours in 65 patients admitted for suspicion of ACS without ST elevation and without clinical, radiological or echocardiographic signs of left ventricular dysfunction. The results of BNP measurements were masked until the final diagnosis was established on the usual investigations (ECG changes, troponine I values, myocardial scintigraphy, coronary angiography). These investigations identified 3 groups of patients: non-Q wave infarction (group A: 19 patients), unstable angina (group B: 21 patients) and non-coronary chest pain (group C: 25 patients). The peak BNP was significantly higher in groups A (210 +/- 172 pg/ml) and B (152 +/- 159 pg/ml) than in group C (16 +/- 14 pg/ml). However, the BNP was normal or only slightly increased (< 50 pg/ml) in 25% of cases of ACS. Analysis of the kinetics of BNP was much more discriminating: early increase after the pain, peak between the 14th and 24th hours (19th hour on average), followed by a progressive decrease. The kinetics were identical in Groups A and B, contrasting with the flat profile of the curve in group C. A change of > 20 pg/ml in BNP was a better criterion of ACS with a diagnostic accuracy > 90% than increased troponine (group A) or undetectable troponine (group B). The authors conclude that BNP kinetics is a new and reliable diagnostic marker of unstable angina when the usual criteria of ACS are not present (notably a normal ECG and undetectable troponine).