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Background Myocardial infarction with non-obstructive coronary arteries (MINOCA) is a common disorder characterized by the presence of clinical criteria for acute myocardial infarction in the absence of obstructive coronary artery disease on angiography. We aim to investigate the relationship between myocardial bridging (MB) and MINOCA. Methods and results An observational retrospective study was conducted on 15 036 patients who had been referred for coronary angiography and who fulfilled the Fourth Universal Definition of Myocardial Infarction. The study population was divided into ST-segment elevation myocardial infarction (STEMI) and non-ST-segment elevation myocardial infarction (NSTEMI) patients, from which we defined two main groups: the MINOCA group and the coronary artery disease (CAD) group. Statistical analyses were carried out by using SPSS, version 20. The prevalence of angiographic MB among the groups was significantly greater in the MINOCA group (2.9% vs. 0.8%). MINOCA accounted for 14.5% of spontaneous myocardial infarction, and the clinical presentation was more frequently NSTEMI rather than STEMI (84.3% vs. 15.7%). After adjusting for confounders, multivariate analyses showed a positive association between MB and MINOCA [odds ratio = 3.28, 95% CI (2.34; 4.61) P Conclusion MB is a risk factor for MINOCA. Because MB prevalence differed significantly between the controls (CAD group) and cases (MINOCA group), which were positively associated to MB, it seems likely that MB would be a potential cause of MINOCA. Investigations for MB in MINOCA cases and especially in NSTEMI patients seem necessary.

Background In the GLOBAL LEADERS trial, ticagrelor monotherapy beyond 1 month compared with standard antiplatelet regimens after coronary stent implantation did not improve outcomes at intention‐to‐treat analysis. Considerable differences in treatment adherence between the experimental and control groups may have affected the intention‐to‐treat results. In this reanalysis of the GLOBAL LEADERS trial, we compared the experimental and control treatment strategies in a per‐protocol analysis of patients who did not deviate from the study protocol. Methods and Results Baseline and postrandomization information were used to classify whether and when patients were deviating from the study protocol. With logistic regressions, we derived time‐varying inverse probabilities of nondeviation from protocol to reconstruct the trial population without protocol deviation. The primary end point was a composite of all‐cause mortality or nonfatal Q‐wave myocardial infarction at 2 years. At 2‐year follow‐up, 1103 (13.8%) of 7980 patients in the experimental group and 785 (9.8%) of 7988 patients in the control group qualified as protocol deviators. At per‐protocol analysis, the rate ratio for the primary end point was 0.88 (95% CI, 0.75–1.03; P =0.10) on the basis of 274 versus 325 events in the experimental versus control group. The rate ratio for the key safety end point of major bleeding was 1.00 (95% CI, 0.79–1.26; P =0.99). The per‐protocol and intention‐to‐treat effect estimates were overall consistent. Conclusions Among patients who complied with the study protocol in the GLOBAL LEADERS trial, ticagrelor plus aspirin for 1 month followed by ticagrelor monotherapy was not superior to 1‐year standard dual antiplatelet therapy followed by aspirin alone at 2 years after coronary stenting. Registration URL: https://www.clinicaltrials.gov ; Unique identifier: NCT01813435.

Background: Because rotational atherectomy (RA) is associated with arterial trauma and platelet activation, patients treated with RA may benefit from more potent antiplatelet drugs. The aim of this trial was to assess the superiority of ticagrelor over clopidogrel in reducing post procedure troponin release. Methods: TIRATROP (TIcagrelor in Rotational Atherectomy to reduce TROPonin enhancement) is a multicenter double-blind randomized controlled trial that included 180 patients with severe calcified lesions requiring RA who received either clopidogrel (300 mg loading dose, then 75 mg/d) or ticagrelor (loading dose 180 mg then 90 mg twice daily). Blood samples were collected at the beginning (T0), and 6, 12, 18, 24 and 36 h after the procedure. Primary end point was troponin release within the first 24 h using area under the curve analysis (troponin level as a function of time). Results: The mean age of patients was 76 ± 10 years, 35% had diabetes. RA was used to treat 1, 2 or 3 calcified lesions in 72%, 23% and 5% of patients, respectively. Troponin release within the first 24 h was similar in both the ticagrelor (adjusted mean ±SD of ln AUC 8.85 ± 0.33) and the clopidogrel (8.77 ± 0.34, p = 0.60) arms. Independent predictors for troponin enhancement were acute coronary syndrome presentation, renal failure, elevated C-Reactive protein and multiple lesions treated with RA. Conclusion: Troponin release did not differ among treatment arms. Our results suggest that greater platelet inhibition does not affect periprocedural myocardial necrosis in the setting of RA.

Background The FREEDOM (Future Revascularization Evaluation in Patients with Diabetes Mellitus: Optimal Management of Multivessel Disease) trial demonstrated that for patients with diabetes mellitus (DM) and multivessel coronary disease (MVD), coronary artery bypass grafting (CABG) is superior to percutaneous coronary intervention with drug-eluting stents (PCI-DES) in reducing the rate of major adverse cardiovascular and cerebrovascular events after a median follow-up of 3.8 years. It is not known, however, whether CABG confers a survival benefit after an extended follow-up period. Objectives The purpose of this study was to evaluate the long-term survival of DM patients with MVD undergoing coronary revascularization in the FREEDOM trial. Methods The FREEDOM trial randomized 1,900 patients with DM and MVD to undergo either PCI with sirolimus-eluting or paclitaxel-eluting stents or CABG on a background of optimal medical therapy. After completion of the trial, enrolling centers and patients were invited to participate in the FREEDOM Follow-On study. Survival was evaluated using Kaplan-Meier analysis, and Cox proportional hazards models were used for subgroup and multivariate analyses. Results A total of 25 centers (of 140 original centers) agreed to participate in the FREEDOM Follow-On study and contributed a total of 943 patients (49.6% of the original cohort) with a median follow-up of 7.5 years (range 0 to 13.2 years). Of the 1,900 patients, there were 314 deaths during the entire follow-up period (204 deaths in the original trial and 110 deaths in the FREEDOM Follow-On). The all-cause mortality rate was significantly higher in the PCI-DES group than in the CABG group (24.3% [159 deaths] vs. 18.3% [112 deaths]; hazard ratio: 1.36; 95% confidence interval: 1.07 to 1.74; p = 0.01). Of the 943 patients with extended follow-up, the all-cause mortality rate was 23.7% (99 deaths) in the PCI-DES group and 18.7% (72 deaths) in the CABG group (hazard ratio: 1.32; 95% confidence interval: 0.97 to 1.78; p = 0.076). Conclusions In patients with DM and MVD, coronary revascularization with CABG leads to lower all-cause mortality than with PCI-DES in long-term follow-up. (Comparison of Two Treatments for Multivessel Coronary Artery Disease in Individuals With Diabetes [FREEDOM]; NCT00086450)

Item does not contain fulltext BACKGROUND: The Synergy between PCI with Taxus and Cardiac Surgery (SYNTAX) trial was a non-inferiority trial that compared percutaneous coronary intervention (PCI) using first-generation paclitaxel-eluting stents with coronary artery bypass grafting (CABG) in patients with de-novo three-vessel and left main coronary artery disease, and reported results up to 5 years. We now report 10-year all-cause death results. METHODS: The SYNTAX Extended Survival (SYNTAXES) study is an investigator-driven extension of follow-up of a multicentre, randomised controlled trial done in 85 hospitals across 18 North American and European countries. Patients with de-novo three-vessel and left main coronary artery disease were randomly assigned (1:1) to the PCI group or CABG group. Patients with a history of PCI or CABG, acute myocardial infarction, or an indication for concomitant cardiac surgery were excluded. The primary endpoint of the SYNTAXES study was 10-year all-cause death, which was assessed according to the intention-to-treat principle. Prespecified subgroup analyses were performed according to the presence or absence of left main coronary artery disease and diabetes, and according to coronary complexity defined by core laboratory SYNTAX score tertiles. This study is registered with ClinicalTrials.gov, NCT03417050. FINDINGS: From March, 2005, to April, 2007, 1800 patients were randomly assigned to the PCI (n=903) or CABG (n=897) group. Vital status information at 10 years was complete for 841 (93%) patients in the PCI group and 848 (95%) patients in the CABG group. At 10 years, 244 (27%) patients had died after PCI and 211 (24%) after CABG (hazard ratio 1.17 [95% CI 0.97-1.41], p=0.092). Among patients with three-vessel disease, 151 (28%) of 546 had died after PCI versus 113 (21%) of 549 after CABG (hazard ratio 1.41 [95% CI 1.10-1.80]), and among patients with left main coronary artery disease, 93 (26%) of 357 had died after PCI versus 98 (28%) of 348 after CABG (0.90 [0.68-1.20], pinteraction=0.019). There was no treatment-by-subgroup interaction with diabetes (pinteraction=0.66) and no linear trend across SYNTAX score tertiles (ptrend=0.30). INTERPRETATION: At 10 years, no significant difference existed in all-cause death between PCI using first-generation paclitaxel-eluting stents and CABG. However, CABG provided a significant survival benefit in patients with three-vessel disease, but not in patients with left main coronary artery disease. FUNDING: German Foundation of Heart Research (SYNTAXES study, 5-10-year follow-up) and Boston Scientific Corporation (SYNTAX study, 0-5-year follow-up).

Background Mean gradient (MG) elevation can be detected immediately post-procedure or secondarily during follow-up. Comparison between these two parameters and impact on outcomes has not previously been investigated. Objectives The study aimed to identify incidence, influence on prognosis and parameters associated with immediate high post-procedural mean transvalvular gradient (PPMG) and delayed mean gradient increase (DMGI), in the FRANCE 2 (French Aortic National CoreValve and Edwards 2) registry. Methods The registry includes all consecutive symptomatic patients with severe aortic stenosis. Three groups were analyzed: 1) PPMG 10 mmHg (control); 2) PPMG 10 mmHg (group 1); 3) PPMG ≥20 mmHg (group 2). Results From January 2010 to January 2012, 4201 consecutive patients were prospectively enrolled in the registry. The control group comprised 2078 patients; the group 1, 131 patients; and the group 2, 144 patients. DMGI exceeded 10 mmHg in 5.6%, and was not associated with greater 4-year mortality than in control group (32.6% vs. 40.1%, p=0.27, respectively). PPMG was at least 20 mmHg in 6.1%, and was associated with higher 4-year mortality than in control group (48.7% versus 40.1%, p=0.005, respectively) (Figure 1). Two-thirds of patients with initial PPMG ≥20 mmHg had finally a MG Conclusions Patients with PPMG >20 mmHg 1 year post-TAVI had higher 4-year mortality than the general population of the registry, unlike patients with MG normalization at 1 year. Figure 1 Funding Acknowledgement Type of funding source: Public Institution(s). Main funding source(s): French National Society of Cardiology

Background We hypothesised that ticagrelor, in combination with aspirin for 1 month, followed by ticagrelor alone, improves outcomes after percutaneous coronary intervention compared with standard antiplatelet regimens. Methods GLOBAL LEADERS was a randomised, open-label superiority trial at 130 sites in 18 countries. Patients undergoing percutaneous coronary intervention with a biolimus A9-eluting stent for stable coronary artery disease or acute coronary syndromes were randomly assigned (1:1) to 75-100 mg aspirin daily plus 90 mg ticagrelor twice daily for 1 month, followed by 23 months of ticagrelor monotherapy, or standard dual antiplatelet therapy with 75-100 mg aspirin daily plus either 75 mg clopidogrel daily (for patients with stable coronary artery disease) or 90 mg ticagrelor twice daily (for patients with acute coronary syndromes) for 12 months, followed by aspirin monotherapy for 12 months. Randomisation was concealed, stratified by centre and clinical presentation (stable coronary artery disease vs acute coronary syndrome), and blocked, with randomly varied block sizes of two and four. The primary endpoint at 2 years was a composite of all-cause mortality or non-fatal centrally adjudicated new Q-wave myocardial infarction as assessed by a core lab in a blinded manner. The key secondary safety endpoint was site-reported bleeding assessed according to the Bleeding Academic Research Consortium criteria (grade 3 or 5). Analysis was by intention to treat. This trial is registered with ClinicalTrials.gov, number NCT01813435, and is closed to new participants, with followup completed. Findings Between July 1, 2013, and Nov 9, 2015, 15 968 participants were randomly assigned, 7980 to the experimental group and 7988 to the control group. At 2 years, 304 (3.81%) participants in the experimental group had died or had a non-fatal centrally adjudicated new Q-wave myocardial infarction, compared with 349 (4.37%) participants in the control group (rate ratio 0.87 [95% CI 0. 75-1. 01]; p=0.073]). There was no evidence for a difference in treatment effects for the primary endpoint across prespecified subgroups of acute coronary syndromes and stable coronary artery disease (p=0.93). Grade 3 or 5 bleeding occurred in 163 participants in the experimental group and 169 in the control group (2.04% vs 2.12%; rate ratio 0.97 [95% CI 0. 78-1. 20]; p=0.77). Interpretation Ticagrelor in combination with aspirin for 1 month followed by ticagrelor alone for 23 months was not superior to 12 months of standard dual antiplatelet therapy followed by 12 months of aspirin alone in the prevention of all-cause mortality or new Q-wave myocardial infarction 2 years after percutaneous coronary intervention. Copright (C) 2018 Elsevier Ltd. All rights reserved. European Clinical Research Institute; Biosensors International; AstraZeneca; Medicines Company; Canada Research Chairs Programme

BACKGROUND Transcatheter aortic valve replacement (TAVR) has revolutionized management of high-risk patients with severe aortic stenosis. However, survival and the incidence of severe complications have been assessed in relatively small populations and/or with limited follow-up. OBJECTIVES This report details late clinical outcome and its determinants in the FRANCE-2 (FRench Aortic National CoreValve and Edwards) registry. METHODS The FRANCE-2 registry prospectively included all TAVRs performed in France. Follow-up was scheduled at 30 days, at 6 months, and annually from 1 to 5 years. Standardized VARC (Valve Academic Research Consortium) outcome definitions were used. RESULTS A total of 4,201 patients were enrolled between January 2010 and January 2012 in 34 centers. Approaches were transarterial (transfemoral 73%, transapical 18%, subclavian 6%, and transaortic or transcarotid 3%) or, in 18% of patients, transapical. Median follow-up was 3.8 years. Vital status was available for 97.2% of patients at 3 years. The 3-year all-cause mortality was 42.0% and cardiovascular mortality was 17.5%. In a multivariate model, predictors of 3-year all-cause mortality were male sex (p = 2 of 4 (p < 0.001). Severe events according to VARC criteria occurred mainly during the first month and subsequently in < 2% of patients/year. Mean gradient, valve area, and residual aortic regurgitation were stable during follow-up. CONCLUSIONS The FRANCE-2 registry represents the largest database available on late results of TAVR. Late mortality is largely related to noncardiac causes. Incidence rates of severe events are low after the first month. Valve performance remains stable over time. (J Am Coll Cardiol 2016; 68: 1637-47) (C) 2016 by the American College of Cardiology Foundation.

The aim of this study was to test the hypothesis that 6-month dual antiplatelet therapy (DAPT) is noninferior to 24-month DAPT in aspirin-sensitive patients.The ITALIC (Is There a Life for DES After Discontinuation of Clopidogrel) trial showed that rates of bleeding and thrombotic events at 1 year were much the same with 6 versus 12 months of DAPT after percutaneous coronary intervention with second-generation drug-eluting stents. In this report, 2-year follow-up is presented.In a multicenter randomized study, patients with confirmed nonresistance to aspirin undergoing drug-eluting stent implantation were allocated to 6 or 24 months of DAPT. The primary endpoint was a composite of death, myocardial infarction, urgent target vessel revascularization, stroke, and major bleeding at 12 months post-percutaneous coronary intervention. The secondary endpoints comprised the same composite endpoint at 24 months and each individual component.Overall, 2,031 patients from 70 centers were screened; 926 were randomized to 6-month and 924 to 24-month DAPT. Noninferiority was demonstrated for 6- versus 12-month DAPT, with an absolute risk difference of 0.11% (95% confidence interval: -1.04% to 1.26%; p = 0.0002). At 2 years, the composite endpoint was unchanged, at 3.5% for 6 months and 3.7% for 24 months (p = 0.79), and rates of myocardial infarction (1.3% vs. 1.0%; p = 0.51), stroke (0.6% vs. 0.8%; p = 0.77), and target vessel revascularization (1.0% vs. 0.3%; p = 0.09) were likewise similar. There was a trend toward higher mortality with longer DAPT (2.2% vs. 1.2%; p = 0.11). Four patients (0.4%) in the 24-month group and none in the 6-month group had major bleeding.Two-year outcomes in the ITALIC trial confirmed the 1-year results and showed that patients receiving 6-month DAPT after percutaneous coronary intervention with second-generation drug-eluting stent have similar outcomes to those receiving 24-month DAPT.

Obesity in patients with heart failure (HF) is a factor of better prognosis, supposedly partly because of the particular epidemiology of HF in this population. This study expected to compare the parameters of severity and mortality in patients with and without obesity, to better understand the origin of this paradox.Two hundred twenty-two patients with nonischemic HF and systolic dysfunction were divided into two groups according to their body mass index (≥ 30 vs.30 kg/m(2), respectively) and explored for functional parameters and prognosis.B-type natriuretic peptide (BNP) levels were lower and peak oxygen consumption higher in patients with obesity. Patients with obesity had a better prognosis than patients without obesity with a 4-year mortality of 11.1% and 26.4%, respectively (P = 0.009). By univariate analysis, obesity was associated with a reduced risk of death: HR 0.52 [0.28-0.99]. This protective effect was no longer present after adjusting for VO2max and BNP level.The obesity paradox is probably partly due to an overestimation of the severity of HF in patients with obesity because of the multifactorial nature of their dyspnea. Obesity no longer has a protective effect after adjustment for the usual prognostic parameters of HF.

To evaluate the safety and effectiveness of the Kaname™ cobalt-chromium (Co-Cr), thin strut, bare metal stent (BMS) system for the treatment of coronary artery lesions.Despite widespread use of drug-eluting stents, a certain percentage of patients with coronary artery disease are still treated with BMS. Therefore, it is essential to evaluate their clinical performance.Two hundred eighty-two patients were enrolled in this prospective, single-arm study including a predefined subset of 79 patients with small vessels. The primary end-point was freedom from target vessel failure (TVF) at 6 months. Key angiographic and intravascular ultrasound (IVUS) end-points were late loss, diameter stenosis, binary restenosis, and neointimal hyperplasia volume.Freedom from TVF at 6 months was 93.3% and at 1 year 90.8% in total population, and 92.4% and 87.3% in small vessels, respectively. Clinically driven target lesion revascularization (TLR) rates at 6 and 12 months were 4.3% and 6.4% in total population, and 3.8% and 7.6% in small vessels, respectively. At 6 months in-stent late loss was 0.75 ± 0.43 mm and binary restenosis rate was 16.9% in total population, and 0.64 ± 0.40 mm and 26.1% in small vessels, while IVUS assessed neointimal hyperplasia volume at 6 months was 128.9 ± 42.6 mm(3) for total population. There were no definite and probable stent thromboses up to 12 months.Results indicate good safety and effectiveness of the Kaname™ stent with clinically equivalent results in small and larger vessels, as such providing useful treatment option for patients with ischemic heart disease considered for BMS implantation.

We compared the efficacy of the Cypher Select (Cordis Corporation, Bridgewater, NJ, USA) sirolimus-eluting stent (SES) versus balloon angioplasty (BA) in in-stent restenosis (ISR) of Taxus or Taxus Liberté paclitaxel-eluting stents (PES; Boston Scientific, Natick, MA, USA) or Cypher/Cypher Select SES.Optimal treatment strategies have not been identified for drug-eluting stent (DES) ISR.Patients with a native coronary artery SES or PES ISR were randomized to SES or BA. In addition, a control group included BMS ISR treated with SES. Angiographic control was performed at 12 months.281 patients were enrolled. Significant differences favoring SES over BA were noted in immediate and net gain (1.39 ± 0.51 vs. 0.97 ± 0.54 mm, P0.0001 and 1.07 ± 0.69 vs. 0.49 ± 0.67 mm, P0.0001), 12-month mean luminal diameter (MLD; 2.14 ± 0.62 vs. 1.71 ± 0.55 mm, P0.0001) and percent diameter stenosis (%DS; 21 ± 19.24 vs. 29.82 ± 18.47, P = 0.001). There was no significant difference at 12 months between SES and BA in the primary end-point late lumen loss (LLL; 0.37 ± 0.57 vs.0.41 ± 0.63, P = 0.73) and in in-stent binary restenosis (11.1% vs. 14%, P = 0.59). Target-lesion revascularization (TLR) was numerically lower in patients treated with SES (5.9% vs. 13.1%, P = 0.097). There was no difference according to the initial DES. In contrast, significantly higher immediate and net gains and MLD were noted in the BMS control group treated by SES.In this angiographic randomized trial comparing SES and BA in SES or PES restenosis, 12 month MLD, immediate and net gain, and %DS favored SES whereas no difference was noted in LLL. Condensed abstract optimal treatment strategies have not been identified for sirolimus-(SES) or paclitaxel-eluting stent (PES) in-stent restenosis (ISR). We randomized patients with a native coronary artery SES or PES ISR to SES or BA. In addition, a control group included BMS ISR treated with SES. There was no difference in the primary end-point, late lumen loss (LLL) at 12 months between the SES and BA groups. However, follow-up MLD and immediate and net gain favored SES.

ARTS-II was designed to evaluate the sirolimus-eluting stent (SES) versus ARTS-I. The objective of this analysis is to assess the safety and efficacy of the SES in diabetic patients with multivessel disease (MVD) versus both arms of ARTS-I.The ARTS studies included 367 diabetic patients (ARTS-II: 159; ARTS-I-CABG: 96; ARTS-I-PCI: 112). Baseline characteristics showed a more diseased patient population in the ARTS-II study: 50.3% with 3VD vs. 35.4% (ARTS-I-CABG) and 30.8% (ARTS-I-PCI) (p=0.003). Treated or anastomosed lesions were 3.2+/-1.2 (ARTS-II), 2.8+/-0.8 (ARTS-I-CABG) and 2.5+/-1.1 (ARTS-I-PCI). At 30 days there was a significant difference in MACCE between ARTS-II (4.4%) and ARTS-I-PCI (12.5%) (p=0.02). At 1-year, the death rate was 2.5% (ARTS-II) vs. 3.1% (ARTS-I-CABG) and 6.3% (ARTS-I-PCI) without significant differences. Myocardial infarction rate was 0.6% (ARTS-II) vs. 2.1% (ARTS-I-CABG; p=0.56) and 6.3% (ARTS-I-PCI; p=0.01). The need for repeat revascularization was 12.6% (ARTS-II) vs. 4.2% (ARTS-I-CABG; p=0.027) and 22.3% (ARTS-I-PCI; p= 0.046). MACCE-free survival was 84.3% (ARTS-II) vs. 85.4% (ARTS-I-CABG; p=0.86) and 63.4% (ARTS-I-PCI; p0.001). Also at 1 year, the overall MACCE rate in patients with diabetes was significantly higher than in nondiabetic patients, 15.7% vs. 8.5%, respectively [RR 1.85, 95%CI (1.16,2.97), p=0.015), due to a higher incidence of death and need for repeat revascularization, 2.5% vs. 0.4 and 12.5% vs. 5.6% in diabetes vs. nondiabetes groups, respectively.Despite more extensive and treated disease, the overall MACCE-free survival in diabetic patients at 1 year in ARTS-II is similar to ARTS-I-CABG.

The purpose of this study was to assess the 3-year outcome of coronary artery bypass graft surgery (CABG) and percutaneous coronary intervention (PCI) using sirolimus-eluting stents (SES) in patients who had multivessel coronary artery disease with and without diabetes mellitus.The optimal method of revascularization in diabetic patients remains in dispute.The ARTS-II (Arterial Revascularization Therapies Study-Part II) trial is a single-arm study (n = 607) that included 159 diabetic patients treated with SES whose 3-year clinical outcome was compared with that of the historical diabetic and nondiabetic arms of the randomized ARTS-I trial (n = 1,205, including 96 diabetic patients in the CABG arm and 112 in the PCI arm).At 3 years, among nondiabetic patients, the incidence of the primary composite of death, CVA, myocardial infarction (MI), and repeat revascularization (major adverse cardiac and cerebrovascular events [MACCE]), was significantly lower in ARTS-II than in ARTS-I PCI (adjusted odds ratio [OR]: 0.41; 95% confidence interval [CI]: 0.26 to 0.64) and similar to ARTS-I CABG. The ARTS-II patients were at significantly lower risk for death, CVA, and MI as compared with both the ARTS-I PCI (adjusted OR: 0.55; 95% CI: 0.34 to 0.91) and ARTS-I CABG patients (adjusted OR: 0.56; 95% CI: 0.35 to 0.92). Among diabetic patients, the incidence of MACCE in ARTS-II was similar to that of both PCI and CABG in ARTS-I. Conversely, the incidence of death, CVA, and MI was significantly lower in ARTS-II than in ARTS-I PCI (adjusted OR: 0.67; 95% CI: 0.27 to 1.65) and was similar to that of ARTS-I CABG.At 3 years, PCI using SES for patients with multivessel coronary artery disease seems to be safer and more efficacious than PCI using bare-metal stents, irrespective of the diabetic status of the patient. Hence, PCI using SES appears to be a valuable alternative to CABG for both diabetic and nondiabetic patients.

Fifteen patients with severely damaged coronary circulation required temporary intraaortic balloon counterpulsation for pharmacologically uncontrollable chest pain and poor haemodynamic state (hypotension or shock) in connection with the transluminal coronary angioplasty procedure. Twenty-five angioplasties were attempted (1.75 artery stem/patient) with a primary success rate of 96%. Emergency surgery was performed only once (6.6%) and no death occurred after the percutaneous therapeutic procedures. One patient died due to a cerebrovascular accident, two other patients suffered sudden death 1 and 3 months later. Two patients finally required coronary bypass surgery, and one patient a repeated angioplasty. In the follow-up period (mean = 11 months), two patients presented moderate symptoms of stable angina pectoris, and 10 patients (83%) remained in satisfactory condition. Temporary diastolic counterpulsation provided in patients with pharmacologically refractory myocardial ischaemia and hypotension or shock an important protection for performing transluminal angioplasty in a good condition, with improved remaining coronary circulation and haemodynamic state, assuring a favourable hospital survival.

This study reports the results of routine evaluation to detect coronary and carotid atherosclerosis in 200 asymptomatic and hypercholesterolemic patients (48 +/- 10 years: 72.5% men). All patients underwent physical examination, blood lipid profile, an exercise test and cervical echo-doppler. If the exercise electrocardiogram was abnormal, a thallium isotope scan and/or coronary arteriography were performed. Hypercholesterolemia was severe (3.03 +/- 0.52 g/l). 77.5% of patients had pure hypercholesterolemia. Carotid atherosclerosis in the form of plaque (27.5%) or stenosis (3.5%) was found in 31% of patients. This carotid atheroma was commoner in older patients (51.9 +/- 9 years as against 47 +/- 10 years, p0.01). Twenty patients (10%) had electrical signs of ischemia provoked by exercise. Six of them had a normal thallium isotope scan and did not undergo coronary arteriography. Coronary arteriography was abnormal in 10 patients (5%): 7 had stenotic lesions and 3 showed evidence of spasm during the methylergometrine test. In total, the hypercholesterolemic patients investigated here were characterised by subclinical atherosclerosis which was frequent but certainly underestimated by non-invasive studies. The existence of an atherosclerotic lesion is an additional argument in favour of starting cholesterol-lowering treatment.

Permanent reciprocating junctional tachycardia (PRJT) is an uncommon type of Tachycardia, usually associated with a retrogradely conducting accessory pathway situated near to the ostium of the coronary sinus. This study reports the localisation of the site of atrial insertion of the accessory pathway, confirmed by the efficacy of intracardiac catheter ablation. Five patients (4 men), aged 14 to 45, experienced PRTJT at rates of 120 to 150/mn over a period of 2 to 15 years. 4 patients were normal, expected in 2 patients in whom they were 16 and 20%. One of these suffered a thromboembolic complication after pharmacological interruption of the tachycardia. The presence of an accessory pathway with decremential retrograde conduction was confirmed in all cases. Catheter ablation was successful in the medio-septal (2 cases), posteroseptal (1 case), lateral (1 case) and anteroseptal (1 case) regions. Six to 30 applications of 20 to 30 watts of radiofrequency energy were used in the 5 cases. In one case (right lateral accessory pathway), a fulguration procedure was necessary with a cathodic shock of 160 Joules. The AV conduction was preserved and retrograde conduction was normalised in all cases. All patients remained asymptomatic for a period of 10 to 43 months without antiarrhythmic therapy. The ejection fractions of the two patients with left ventricular dysfunction returned to normal. The authors conclude that the accessory pathways of PRJT may be situated in different regions of the right atrium. The efficacy of catheter ablation was 100 % in this form of tachycardia.

The aim of the ESTIM Midi-Pyrénées survey was to monitor the management of acute coronary syndrome with ST segment elevation by cardiologists and emergency departments in the Midi-Pyrénées region. Over a period of 2 years between June 2001 and June 2003, 1287 patients presenting with acute coronary syndrome within the first 24 hours were recruited prospectively. The initial management of these patients was undertaken either by a mobile medical team in the pre-hospital phase, or in a hospital emergency department, non-interventional cardiology department or an interventional cardiology department in 51.8%, 28.8%, 9.6% et 9.9% of cases respectively. Depending on these four modes of initial management, the median time for initial management was 1h30, 2h45, 4h30 et 4h respectively. Emergency coronary reperfusion was proposed in 89.6% of cases. Of the patients in whom reperfusion was attempted within the first 12 hours, 33.7% underwent pre-hospital thrombolysis (median delay of 1h48), 35.8% underwent thrombolysis in hospital (median delay 3h), and 30.4% underwent primary angioplasty (median delay 4h40). Thrombolysis was followed by angioplasty in 80% of cases. A combined approach with thrombolysis and angioplasty was applied in 41% of patients. At one month the rate of major cardiac events, death, and/or subsequent myocardial infarction was 12%. Multivariate analysis revealed that the only significant adverse prognostic features were: not offering reperfusion [Odds ratio (OR) 4, confidence interval (CI) 2.3-3.7] and age [OR 3.8, CI 2.3-6.2]. The method of reperfusion did not influence the subsequent outcome in this regional survey.pre-hospital management allows early revascularisation. In our region there was no significant prognostic difference between pre-hospital thrombolysis and primary angioplasty. It shows that the logistic and therapeutic potentials of prehospital care are not being sufficiently exploited.

The objective of this study was to compare the results of the management of dyslipidaemic patients in the community with the objectives fixed by the AFSSAPS recommendations. An observational epidemiological study was set up among 4 000 general practitioners and 527 cardiologists. This study included 22 323 patients (average age 60.6 years) affected by a documented primary dyslipidaemia. The average number of associated risk factors, according to the AFSSAPS criteria, was 1.8. The prevalence of secondary prevention in patients was 17.5%. More than 80% of patients were being treated by a lipid lowering agent (fibrate or statin) combined or not with lifestyle guidelines. In primary prevention, although the target levels of LDL-C fixed by the AFSSAPS were attained in 94.4% and 82.6% respectively for patients with no other risk factor or with one associated risk factor, the objectives were reached in only 55.4% of patients with two other risk factors and in 29.6% of patients with more than two other risk factors. In secondary prevention, the AFSSAPS objectives were attained in only 45.2% of patients. Following this lipid result, 34.8% of patients underwent therapeutic adjustment, principally the use of medication in the patients receiving lifestyle advice or reinforcement of pharmacological treatment. This study underlines the inadequate management in France of dyslipidaemic patients in the community.

To evaluate the results of the association of a percutaneous transluminal renal angioplasty before a surgical revascularization of the infra-renal aorta.Percutaneous transluminal angioplasty of one (n = 12) or two (n = 2) renal arteries have been performed in 14 patients (11 hypertensive and one with azotemia), 2 to 240 days (mean 54) before infra-renal aortic surgery (aneurysms: 8, occlusive disease: 6).15 of the 16 dilatations were completely technically successful (residual stenosis less than 20%), with one groin hematoma treated medically. Mean duration of the surgical intervention were 137 minutes (occlusive disease) and 147 minutes (aneurysm). In the post-operative course were noted resolutive infections in two patients, and one death because of myocardial infarction. At the end of the follow-up (3 to 60 months, mean 32), all of the 13 patients alive had improved in terms of vascular disease. Hypertension was improved for 2 patients, stable for 10, worse for 1. Creatinine serum level was stable for 12 patients, and the renal insufficient was worsened.Combined percutaneous transluminal renal angioplasty and aortic revascularization seems to be reliable and safe; it can be an alternative to a simultaneous aortic and renal revascularization, notably for high-risk patients.

In the catheter laboratory, faced with a patient with unstable angina, the problem is not the diagnosis of epicardial coronary artery stenosis but rather the atherothrombotic complexity of the stenosis and the identification of other less stenotic lesions on angiographically normal or nearly normal segments. The authors describe two appearances with morphological analysis of the vulnerable or unstable plaque and functional analysis of coronary artery vasomotricity. Acute coronary syndromes due to a clearly stenotic atherothrombotic plaque on angiography pose no diagnostic problems. However, an acute coronary syndrome may be more difficult to assess when angiography shows only simple irregularities of the lumen or no lesions at all. In these cases, angiography is said to be normal and the coronary arteries are considered to be possibly "healthy". Evaluation of the vessels' vasomotricity is especially valuable in this context. Using pharmacological stress tests, endovascular ultrasonography is a complementary diagnostic tool which allows identification of the unstable atheromatous process or of a partial atherothrombosis masked by positive remodelling process. These tests may also indicate the optimal treatment.

Mixed venous oxygen saturation (SVO2) is an haemodynamic parameter of cardiovascular function. The object of this study was to measure SVO2 during percutaneous transluminal coronary angioplasty (PTCA) with prolonged balloon inflation in order to evaluate haemodynamic tolerance more precisely in two groups of patients. Twenty-six patients undergoing PTCA were divided into two groups: Group I, N = 15, with single vessel disease and good left ventricular function (EF: 61.63 +/- 10.1%); Group II, N = 11, with triple vessel disease and poor left ventricular function (EF: 48.05 +/- 14%; p0.05). Continuous monitoring of SVO2 with an oximetrix fiber optic catheter was performed in all patients during PTCA. Irrespective of the duration of balloon inflation, a significant correlation was observed between the changes in cardiac output and VSO2. Given that arterial oxygen pressure, global oxygen consumption and haemoglobin concentrations remained constant during balloon inflation, SVO2 was an indicator of cardiac output.

A two-dimensional echocardiography was performed in the acute phase of myocardial infarction in 140 consecutive patients admitted to hospital for transmural infarction 12 +/- 3 days on average after necrosis was formed. The examination consisted of 4 ventricular sections, including 2 through the apex: 8 ventricular segments were individualized, to be interpreted only when 50 p. 100 of the endocardium was visualized. An echocardiographic score was devised for the kinetics of each ventricular segment, i.e.: -1:dyskinetic, 0:akinetic, +1:hypokinetic, +2: normal, +3:hyperkinetic. The maximum score corresponding to normal contraction of all segments was 16. The hospital results were a mean score of 6.52 +/- 2.90 for 73 anterior and/or lateral infarctions and a mean score of 12.5 +/- 2.38 for 67 inferior infarctions (p less than 0.001). Correlations between echographic scores and angiographic ejection fractions were studied in 99 of the 140 patients. Good correlation between the two examinations was found in 91 cases, with a less than or equal to 6/16 score corresponding to a less than or equal to 40 p. 100 ejection fraction, and a greater than or equal to 7/16 score to a less than or equal to 40 p. 100 ejection fraction. This showed that echocardiography can be relied upon to detect abnormalities of left ventricular kinetics in myocardial infarction. 137 patients were followed up for a mean period of 16.4 months (range: 12 to 25 months). The follow-up was clinical and included angina, recurrent or extended infarction, heart failure, aorto-coronary bypass and mortality.(ABSTRACT TRUNCATED AT 250 WORDS)

A 41-year-old woman with systemic lupus erythematosus and lupus anticoagulant developed aortic thrombosis. The patient was receiving low dose aspirin. Aortography showed a complete obliteration of the infrarenal aorta. Computed tomography and magnetic resonance imaging showed no evidence of aortitis. The patient improved with medical treatment. Six other published cases are reviewed.

In addition to the assessment of the arterial lumen and coronary stenosis, endocoronary ultrasonography also provides information in vivo on the nature of atheromatous plaque. This study reports the preliminary correlations between the echographic appearances, the functional status of the patients and histological data of tissue obtained by directional atherectomy. The appearances of atheromatous infiltrations help distinguish stable forms of coronary disease with "hard", hyperreflective plaques, from acute forms with "soft" hyporeflective plaques. Ultrasonography confirms the clinico-pathological relationship of myocardial infarction and unstable angina with, in the acute forms, a similarity of the culprit plaques which appear vulnerable, hyporeflective and often complicated by the association of fissures and thrombus. The correlations with histological data are still incomplete. However, the "soft" nature of the plaque is an expression of its cellularity and lipid content whereas "hard" plaques correspond to increased fibrous tissue. These associations have no correlative values as yet. Nevertheless, they establish a parallelism which may eventually explain the functional variability and evolutivity of coronary artery disease. In the same way that visualisation of coronary stenosis led to the development of coronary artery surgery and later to angioplasty, observation of the plaque by ultrasonography should promote the development of pharmacological agents to treat the atheromatous lesions.

Latrogenic fistula between the aorta and coronary vein is a rare complication of coronary bypass surgery due to accidental venous or arterial graft onto a coronary vein. The authors report a case of a patient admitted to hospital 2 months after coronary bypass surgery for cardiac failure due to a iatrogenic fistula by implantation of the left internal mammary artery on the great coronary vein. This presentation led to the choice of percutaneous embolisation of the fistula by the release of 6 coils. Based on a review of the literature, this clinical case illustrates the feasibility and value of percutaneous embolisation of iatrogenic fistulae.

Between October, 1985 and June, 1987, 125 patients aged 70 years or more were admitted to the Cardiology Department of Purpan Hospital, Toulouse for unstable angina pectoris. 107 of these patients have been followed up, i.e.: 76 men and 31 women aged from 70 to 85 years (mean 74.5 +/- 3.2 years). 49 patients (46 p. 100) had angina at rest of the intermediate syndrome type; 46 (43 p. 100) had rapidly progressive effort angina, and 12 (11 p. 100) had effort angina de novo. The patients' general condition was preserved in 85 p. 100 of the cases and altered in 15 p. 100. ECG was normal in only 10 p. 100 of the patients; it showed signs of established ischaemia in 70 p. 100 of the cases and sequelae of infarction in 23 p. 100. The mean cardiothoracic ration was 49.9 +/- 4.8 p. 100. The ejection fraction was 62 +/- 14.6 p. 100, the end-diastolic volume 86.9 +/- 32.2 ml/m2 and the left ventricular end-diastolic pressure 15.8 +/- 7.2 mmHg. 69 patients (64.5 p. 100) had calcifications in their coronary arteries. At coronary arteriography 21 patients (19.6 p. 100) showed stenosis of the main stem, 11 patients (10.3 p. 100) had a single vessel disease, 28 (26.2 p. 100) a two-vessel disease and 47 (43.9 p. 100) a three-vessel disease. Treatment was medical in 41 patients (38.3 p. 100) and surgical in 44 patients (41.12 p. 100); transluminal coronary angioplasty (TCA) was performed in 23 patients (21.5 p. 100).(ABSTRACT TRUNCATED AT 250 WORDS)

This study reports two cases of acute severe Coxsackie virus B4 myocarditis in which the immediate clinical signs suggested the acute phase of myocardial infarction, apparently antero-lateral in the first case in a context of cardiogenic shock and infero-lateral in the second case, in the context of acute pulmonary edema. Both cases were characterized by the severity of the initial signs. Numerous other cases of acute Coxsackie virus B myocarditis, simulating myocardial infarction, have been reported in the literature and these contexts deserve to be recognized earlier as they call for specific treatment. The immediate outcome was favorable in both cases but required massive cardiological intensive care in the first patient. Long term follow-up was excellent.

Among 498 patients hospitalised for myocardial infarction during a three year period, 194 (39%) were aged over 70 (mean age: 78.6 +/- 6), including 99 women and 95 men. Comparison of this group of patients with those aged under 70 showed a significantly higher hospital mortality (17.5% v. 6.5%) (p0.01) and a higher acute complication rate (60.8% v. 23.7% (p0.01), in particular after the age of 75. Twenty-eight patients were treated by thrombolysis (14.4% v. 50.6%) (p0.05), with a 79.2% patency rate in follow-up angiography at 48 h, and only one non-fatal hemorrhagic complication. Eighty-six patients were investigated by coronary arteriography (44.9% v. 87.2% (p0.05) without any complication. Mean ejection fraction was 57.3 +/- 13.5%. Fifty patients were treated by angioplasty (24.6% v. 57%) (p0.01) including 15 during the acute phase, with primary success in 40 of them (80%). Ten patients underwent coronary bypass following their infarction (5.1% v. 6.25%) (NS) with two per- or postoperative deaths (20%). Follow-up study revealed high secondary mortality with an overall survival rate at one year of 59.6% v. 81% in patients aged under 70 (p0.01). In total, infarction in the elderly is characterised by high mortality and morbidity as compared with infarctions in patients aged under 70, and requires active management during the acute phase, assessed according to the physiological status and age of the patient.

To determine if impairment of left ventricular filling is influenced by acute myocardial infarction in patients with arterial hypertension, left ventricular diastolic function was assessed by pulsed doppler echocardiography in 46 patients (pts) subdivided into four groups (Gr): G.1 (n = 12 pts) with acute myocardial infarction and hypertensive heart disease. G.2 (n = 12 pts) acute myocardial infarction without arterial hypertension. G.3 (n = 10 pts) arterial hypertension without history of coronary artery disease. G.4 (n = 12 pts) healthy subjects. Coronary angiography and left ventricular cineangiogram was performed in 24 pts (G.1 + G.2). Peak mitral flow velocity (cm/s) in early diastole (E), atrial systole (A), A/E and int A/int E ratios were measured by pulsed doppler. Age and heart rate were statistically similar in all groups. No difference was found among G.1 and G.2 in ejection fraction, and left ventricular segmental kinetic. (tables; see text) Conclusion left ventricular filling is impaired in pts with arterial hypertension and in pts with acute myocardial infarction; acute myocardial infarction increase the impairment of left ventricular diastolic function in pts with hypertensive heart disease.

Linear renal pelvis calcifications in a native kidney due to Corynebacterium urealyticum are described. These micro-organisms have an opportunistic behaviour and can be responsible for nosocomial urinary tract infection. Alkaline incrusted cystitis with linear vesical calcifications are considered as the most typical pattern. Renal pelvis may also be concerned, with parietal calcifications.

Many enzyme systems such as glutathione peroxidase (GPx) or superoxide dismutase (SOD) neutralise the oxygen derived free radicals produced during myocardial reperfusion by thrombolysis. Erythrocytic SOD, plasma and erythrocytic GPx and their cofactor selenium, substances reacting with thiobarbituric acid (TBARS) were analysed by repeated sampling between T0 and 48 hours in 24 patients treated by thrombolysis for acute myocardial infarction. Angiographic control was undertaken systematically between 60 and 180 minutes after initiating thrombolytic therapy: 18 patients had a patent vessel and 6 patients had an occluded vessel recanalised in 5 cases by angioplasty. Biological analysis was performed in the 23 patients successfully revascularised by thrombolysis, eventually completed by angioplasty. The plasma GPx decreased non-significantly between T0 and 2 hours from 246.8 +/- 53.3 to 233 +/- 39 U/ml with a significant increase between 2 and 48 hours from 233 +/- 39.2 to 294 +/- 76 U/ml, whereas the erythrocytic GPx rose significantly and constantly between T0 and 48 hours from 34.8 +/- 7.1 to 37.6 +/- 7.5 U/gHb with significant consumption of selenium between T0 and 4 hours from 81.2 +/- 14 to 68.5 +/- 12.6 micrograms/l. The erythrocytic SOD increased significantly between T0 and 48 hours from 318.9 +/- 40.8 to 337 +/- 59 U/gHb. Finally, the analysis of plasma TBARS showed a non-significant rise between T0 and 30 minutes from 1.59 +/- 0.30 to 1.71 +/- 1.43 mm/l with a return to the basic line values after about 2 hours. These results show a significant increase in the activity of enzymes protecting against the liberation of oxygen free radicals, such as erythrocyte or plasma GPx and erythrocyte SOD between T0 and 48 hours with consumption of selenium, cofactor of GPx, and an increase in circulating lipid peroxydes in acute myocardial infarction treated by thrombolysis. They also illustrate the oxidative stress which occurs in this situation.