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Poor oral health has been linked to coronary heart disease (CHD). Clustering clinical oral conditions routinely recorded in adults may identify their CHD risk profile. Participants from the Paris Prospective Study 3 received, between 2008 and 2012, a baseline routine full-mouth clinical examination and an extensive physical examination and were thereafter followed up every 2 y until September 2020. Three axes defined oral health conditions: 1) healthy, missing, filled, and decayed teeth; 2) masticatory capacity denoted by functional masticatory units; and 3) gingival inflammation and dental plaque. Hierarchical cluster analysis was performed with multivariate Cox proportional hazards regression models and adjusted for age, sex, smoking, body mass index, education, deprivation (EPICES score; Evaluation of Deprivation and Inequalities in Health Examination Centres), hypertension, type 2 diabetes, LDL and HDL serum cholesterol (low- and high-density lipoprotein), triglycerides, lipid-lowering medications, NT-proBNP and IL-6 serum level. A sample of 5,294 participants (age, 50 to 75 y; 37.10% women) were included in the study. Cluster analysis identified 3,688 (69.66%) participants with optimal oral health and preserved masticatory capacity (cluster 1), 1,356 (25.61%) with moderate oral health and moderately impaired masticatory capacity (cluster 2), and 250 (4.72%) with poor oral health and severely impaired masticatory capacity (cluster 3). After a median follow-up of 8.32 y (interquartile range, 8.00 to 10.05), 128 nonfatal incident CHD events occurred. As compared with cluster 1, the risk of CHD progressively increased from cluster 2 (hazard ratio, 1.45; 95% CI, 0.98 to 2.15) to cluster 3 (hazard ratio, 2.47; 95% CI, 1.34 to 4.57; P < 0.05 for trend). To conclude, middle-aged individuals with poor oral health and severely impaired masticatory capacity have more than twice the risk of incident CHD than those with optimal oral health and preserved masticatory capacity (ClinicalTrials.gov NCT00741728).

Aims A number of insulin regimens are used in type 2 diabetes. This analysis aims to better understand the evolution of insulin therapy in different regions of Europe. Methods Data from people starting any insulin were collected in eastern Europe (EEur: Croatia, Russia, Ukraine), northern Europe (NEur: Finland, Germany, UK) and southern Europe (SEur: France, Italy, Portugal, Spain). Retrospective data on starting insulin and prospective follow-up data were extracted from clinical records. Results At 4 years, 1699 (76.0%) of 2236 eligible people had data. EEur participants were mostly female, younger and had shorter diabetes duration on starting insulin, yet had highest baseline HbA1c and more micro-/macrovascular disease. A majority (60%–64%) in all regions started on basal insulin alone, declining to 30%–38% at 4 years, with most switching to basal + mealtime insulin regimen (24%–40%). Higher baseline (28%) and 4-year use (34%) of premix insulin was observed in NEur. Change in HbA1c (SD) ranged from −1.2 (2.1)% (−13 [23] mmol/mol) in NEur to −2.4 (2.0)% (−26 [22] mmol/mol) in EEur. Weight change ranged from +1.9 (8.3) kg in NEur to +3.2 (7.0) kg in SEur. Overall documented hypoglycemia ranged from 0.3 (1.3) to 1.3 (4.4) events/person/6-months (NEur vs. EEur, respectively) and was stable with time. Severe hypoglycemia rates remained low. Conclusion When starting insulin, HbA1c and prevalence of complications were higher in EEur. Regional differences exist in choice of insulin regimens in Europe. However, people starting insulin improved and sustained their glycemic control regardless of regional differences or insulin regimens used.

Aims The EURO-ENDO registry aimed to study the management and outcomes of patients with infective endocarditis (IE). Methods and results Prospective cohort of 3116 adult patients (2470 from Europe, 646 from non-ESC countries), admitted to 156 hospitals in 40 countries between January 2016 and March 2018 with a diagnosis of IE based on ESC 2015 diagnostic criteria. Clinical, biological, microbiological, and imaging [echocardiography, computed tomography (CT) scan, 18F-fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG PET/CT)] data were collected. Infective endocarditis was native (NVE) in 1764 (56.6%) patients, prosthetic (PVIE) in 939 (30.1%), and device-related (CDRIE) in 308 (9.9%). Infective endocarditis was community-acquired in 2046 (65.66%) patients. Microorganisms involved were staphylococci in 1085 (44.1%) patients, oral streptococci in 304 (12.3%), enterococci in 390 (15.8%), and Streptococcus gallolyticus in 162 (6.6%). 18F-fluorodeoxyglucose positron emission tomography/computed tomography was performed in 518 (16.6%) patients and presented with cardiac uptake (major criterion) in 222 (42.9%) patients, with a better sensitivity in PVIE (66.8%) than in NVE (28.0%) and CDRIE (16.3%). Embolic events occurred in 20.6% of patients, and were significantly associated with tricuspid or pulmonary IE, presence of a vegetation and Staphylococcus aureus IE. According to ESC guidelines, cardiac surgery was indicated in 2160 (69.3%) patients, but finally performed in only 1596 (73.9%) of them. In-hospital death occurred in 532 (17.1%) patients and was more frequent in PVIE. Independent predictors of mortality were Charlson index, creatinine > 2 mg/dL, congestive heart failure, vegetation length > 10 mm, cerebral complications, abscess, and failure to undertake surgery when indicated. Conclusion Infective endocarditis is still a life-threatening disease with frequent lethal outcome despite profound changes in its clinical, microbiological, imaging, and therapeutic profiles.

AIMS: To examine the relationships between glycated haemoglobin (HbA1c) and cardiovascular (CV) events in people beginning insulin in routine clinical practice in Europe, North America and Asia in a non-interventional study, the Cardiovascular Risk Evaluation in people with Type 2 Diabetes on Insulin Therapy (CREDIT) study. METHODS: Data on 2999 people were collected prospectively over 4 years from physician reports. The primary outcome was the composite of stroke or myocardial infarction (MI) or CV-specific death. Events were blindly adjudicated. The relative hazards of CV events were described from Cox proportional hazards models incorporating patient risk factors, with updated average HbA1c as a time-dependent covariate. The relationship of severe and symptomatic hypoglycaemia (collected during the 6 months before yearly ascertainment) with CV and all-cause mortality was examined. RESULTS: A total of 147 primary events were accrued during up to 54 months of follow-up. In all, 60 CV-specific deaths, 44 non-fatal MIs and 57 non-fatal strokes occurred, totalling 161 events. There was a significant positive relationship between updated mean HbA1c and primary outcome: hazard ratio (HR) 1.25 [95% confidence interval (CI) 1.12-1.40; p

Homocysteine and vitamins B were correlated with coronary artery disease in patients undergoing diagnostic coronary angiography. 160 patients havingor =1 stenosis (G1), 55 patients having normal coronary arteries (G2) and 171 healthy volunteers (G3) were prospectively recruited. Homocysteine levels were significantly higher in patients, particularly in those with normal coronary angiograms, than in healthy subjects (13.8 +/-6.3 micromol/L in G1 (p0.0001) and 15.2 +/- 8.8 micromol/L in G2 (p0.0001) versus 10.1 +/- 3.1 micromol/L in G3). Homocysteine levels were not related to the extent of coronary artery disease. In patients with normal angiogram, vitamin B12 and folate levels were significantly higher compared with the other groups (p0.05 and p0.001, respectively) showing that vitamin B deficiency was not involved in the hyperhomocysteinemia. In conclusion, homocysteine and vitamins B levels do not contribute to discriminate for the presence of coronary artery disease in patients undergoing diagnostic coronary angiography. Homocysteine levels, however, were higher in patients referred for coronary angiography than in healthy controls.

To assess gender differences in characteristics, management, and hospital outcomes in patients participating in the French FAST-MI 2010 registry.Three thousand and seventy-nine patients hospitalised for ST-elevation (STEMI) or non-ST-elevation (NSTEMI) myocardial infarction in 213 French centres during a 1-month period at the end of 2010.Women account for 27% of the population and more frequently present with NSTEMI. They are 9 years older than men on average, although 25% of women with STEMI are less than 60 years of age. Management of STEMI is similar, after adjustment for baseline characteristics. However, fewer women are treated with primary percutaneous coronary angioplasty. In NSTEMI, although use of coronary angiography is similar, fewer women get treated with angioplasty. Most medications are used in a similar way in men and women, except thienopyridines, with fewer women receive prasugrel. After adjustment, in-hospital mortality is similar for men and women.Myocardial infarction is not specific to men: one out of four patients admitted for myocardial infarction is a woman. Initial management is rather similar for men and women, after taking into account differences in baseline characteristics. Percutaneous coronary angioplasty, however, remains less frequently used in women. In-hospital complications have become rarer and do not differ according to sex.

To evaluate incidence and determinants of arterial hypertension after 60 years.Four thousand nine hundred and forty one subjects aged 60 years or above (2505 men: 64.2±4.2 years; 2436 women: 64.8±4.3 years) were explored two times at the IPC center, Paris, between 1992 and 2007, and were normotensive at the first visit (V1): systolic BP (SBP) less than 140mmHg and diastolic BP (DBP) less than 90mmHg without treatment. The delay between the two visits was 5.8±2.2 years. At the second visit, population was analysed as normotensives and hypertensives. An age-adjusted Anova compared groups.In men, incidence of hypertension is 41.5% and 25.9% for isolated systolic hypertension. In women, incidences were 37.8% and 27.8% respectively. Baseline characteristics for V2-hypertensives showed higher SBP, DBP, BMI, heart rate, glycemia, ECG abnormalities thanV2-normotensives but they had lower physical activity. The determinants of hypertension were: SBP, age, BMI, DBP, glycemia, and lack of physical activity for this age class.From 60 years old, 6-year incidence of hypertension is about 40% and 26% for isolated systolic hypertension, this latter being higher in women. Regular physical activity is protective.

Bivalirudin, with provisional GP IIb/IIIa inhibitor use allows the same protection against ischemic complications while reducing the hemorrhagic complications compared with the systematic association of a GP IIb/IIIa inhibitor plus heparin (The Randomized Evaluation in PCI Linking Angiomax to Reduced Clinical Events-2 [Replace-2]). In clinical practice, the use of heparin is not systematically associated with a GP IIb/IIIa inhibitor. That's why we studied the clinical and economic interest of bivalirudin only versus heparin (UFH) only. Opened pragmatic monocentric study carried out in 2007. We made a chronological matching: for each patient treated with bivalirudin, we included the next patient with the same clinical presentation treated with unfractionated heparin. Ninety-two patients were included (46 in each group). The need for a GP IIb/IIIa inhibitor during the PCI was not significantly different between the two groups (p=0.11). No major hemorrhagic complications were observed in the two groups. Prevalence of ecchymosis was not significantly different: 22 % in the UFH group versus 13 % in the bivalirudin group (p=0.27). The average troponin level the next day was significantly higher in the bivalirudin group (p=0,049), although the change in troponin levels before and after the procedure was similar in the two groups. The average cost by patient of anticoagulation by bivalirudin and HNF is very different, respectively 473+/-150 and 51+/-146 euro (p=0.0001). Bivalirudin can be an interesting alternative for patients with a high risk of having complications. But considering its cost this therapy must be used only for selected patients.

Drug-eluting stents (DES) are known to dramatically reduce restenosis. However, they are more expansive than bare-metal stents (BMS) and they require prolonged dual antiplatelet therapy. In France, the French Society of Cardiology and the "Haute Autorité de santé" have defined recommendations for the use of DES (restricted to patients in high-risk group). The aim of this work was to evaluate our practice (whether these recommendations were well respected or not in our center). Between November 2007 and January 2008 then November 2008 and January 2009 we evaluated all Percutaneous Coronary Interventions (PCI). Two hundred and sixteen (216) patients (mean age 65 ± 13 years, 164 (76 %) were males and, 41 (19 %) were diabetics) had a PCI for stable angina or silent ischemia (47 %), unstable angina or acute coronary syndrome (ACS) ST- (26 %), ACS ST+48 hours (24 %) or ACS ST+48 hours-1 month (3 %). Two hundred and seventy six (276) stents were used, including 35 % of DES. The recommendations were well respected in 82 % of cases. However, 27 % of BMS were implanted in patients in whom DES were indicated. The French recommendations for DES are a reference to help practitioners, but they require to be adapted to each patient, depending on clinical state and their ability to be treated with prolonged dual antiplatelet therapy.

Elevated plasma homocysteine is a risk factor for coronary artery disease (CAD) and thromboembolic disorders that seems also to be associated with chronic heart failure.To evaluate the association between homocysteine and left ventricular dysfunction and to assess whether it is independent of CAD.A prospective study evaluated this relationship in 709 patients referred for diagnostic coronary angiography, including 515 CAD and 194 patients without evidence of coronary artery lesions.The homocysteine level was significantly higher in the 187 patients with a left ventricular ejection fraction (LVEF) dysfunction40% (P0.0001) than in those without ventricular dysfunction. LVEF, NYHA functional class II or III and CAD, stable angina and hypertension were clinical characteristics that influenced total homocysteine level in univariate analysis. Homocysteine was significantly associated with LVEF and N-terminal pro-B-type natriuretic peptide (NT-pro-BNP) in univariate regression (r = -0.267, 95% CI -0.33 to -0.19, P0.0001, and r = 0.381, 95% CI 0.28-0.47, P0.0001, respectively) and in multiple regression (P = 0.0022 and P = 0.0001, respectively). Other determinants were creatinine and vitamin B(12), but not folate. LVEF was a predictor of homocysteine15 micromol L(-1) in the whole population (P for trendor = 0.0001) and in patients without documented CAD (P for trend = 0.0058).Our results showed an association of homocysteine with left ventricular systolic dysfunction and NT-pro-BNP that existed independently of documented CAD. Whether this association reflects a causative factor or a consequence of CHF and influences the prognosis of the disease remains an open question.

To evaluate the therapeutic management of cardiac failure after myocardial infarction (MI) in French intensive cardiac care units (USIC) in 2005.French cross-sectional observational study conducted in USIC of University Hospital Centres (CHU), General Hospital Centres (CHG), and private clinics. Included patients were hospitalized for MI, with a systolic ejection fractionor =40% and "having" or "having had" signs of acute heart failure during the hospitalization or diabetes.Overall, 59 sites, including 10 CHU (16.9%), 37 CHG (62.7%), and 12 private clinics (20.3%) included 447 patients. The majority of patients were male (64.9%),or =70 years (62.7%), hypertensive (53.5%) and diabetic (40.8%). They presented a class II (22.3%), class III (29.5%) and class IV (38.9%) cardiac failure severity according to NYHA classification and 20.4% had a creatinine clearance30 ml/min. The most prescribed treatments were statines (75.4%), IEC (73.6%), diuretics (71.8%) and betablockers (66.7%). The least prescribed were aldosterone antagonist (16.3%) and calcium channel blockers (6.5%). Treatments were prescribed according to age, degree of cardiac failure and renal function of the patient.The present observational study shows improved compliance with European and international guidelines, as regards the medications prescribed at hospital discharge after myocardial infarctions complicated with left ventricular dysfunction. Unfortunately, recommended medications remained less often prescribed in the patients with the most severe characteristics.

The interaction between the use of percutaneous coronary intervention (PCI) for non-ST-elevation acute coronary syndromes and the use of secondary prevention medications was analysed in the French S-Témoin Registry.The population consisted of 2433 patients seen by their cardiologists at an outpatient clinic 2-12 months after non ST-elevation ACS; the survey was carried out from September 2004 to April 2005.Overall, patients undergoing PCI (75% of the population) had higher levels of prescription of recommended secondary prevention medications. Multivariate logistic regression analysis showed that the use and type of coronary intervention (drug eluting versus bare metal stents) was an independent correlate of the use of dual antiplatelet therapy. In addition, time from the acute episode was also a strong correlate of dual antiplatelet therapy. Statins were also more often used in patients with PCI.Patients not treated with PCI are less likely to receive appropriate secondary prevention medications after non ST-elevation acute coronary syndromes. Specific efforts should be directed towards these patients, in particular as regards the prescription of dual antiplatelet therapy.

MEASUREMENT of the proton magnetic resonance relaxation times allows the noninvasive detection of myocardial oedema and has been demonstrated to detect acute allograft rejection in animals. Preliminary reports using conventional magnetic resonance imaging (MRI) sequences in human, however, have given discordant results. We have previously reported that the proton myocardial relaxation times could be precisely determined in healthy subjects by combined spin-echo and inversion-recovery MRI sequences on a moderate field strength (0.5 T) magnet. In order to be routinely feasible in most patients having a suspected acute rejection, this procedure was modified to a single spin-echo/inversion-recovery (“black blood”) sequence which allows a rapid and precise determination of the myocardial transversal relaxation time (T2). The aim of this study was to determine the ability of this MRI procedure for the routine detection and prediction of acute heart transplant rejection.

To compare processes of care for acute myocardial infarction among patients admitted to alpine vs other French hospitals.Prospective observational study of patients with ST-elevation and non ST-elevation myocardial infarction of less than 48 hours hospitalized in 369 intensive care units in November 2000.Fifty-five patients were enrolled in nine alpine hospitals and 2265 patients in 360 other French hospitals. Patients baseline characteristics did not differ between the two groups with the exception of ST-elevation myocardial infarction which was less frequent in patients admitted to alpine hospitals (71 vs. 83%, P = 0.02). Patients living in the alpine area were less likely to be admitted to hospitals with on-site cardiac catheterization facilities (42 vs. 60%, P0.01) although the use of primary (20%) and rescue (24%) percutaneous coronary intervention did not differ significantly between the two groups. There were no differences in the use of medical treatments between the two groups with the exception of low-molecular-weight heparin. The risk of in-hospital death and complications did not differ significantly between the two groups while the risk of death at one year was lower in patients admitted to alpine hospitals (5 vs. 16%, P = 0.04).In 2000, a lower proportion of patients living in the alpine area had access to hospitals with cardiac catheterization facilities compared to other French patients. This finding supports the creation of an additional cardiac catheterization laboratory with experienced operators performing percutaneous coronary interventions 24 hours/7 days and the implementation of an emergency medical care network for acute coronary syndromes in the alpine area.

A pharmacoepidemiological cross-sectional observational study was performed among a representative sample of French general practitioners and cardiologists. The aim of this study was to describe the prescription modalities of flecainide acetate, an Ic class antiarrhythmic, and how these modalities match the marketing authorization and the current summary of product characteristics. A total of 941 physicians participated in the study, 496 GPs and 445 cardiologists, and 1116 patients treated with flecainide for more than one month were included. On average, the patients were 68.7-years-old and 54% of them were women. Most of the initial flecainide prescriptions came from cardiologists (96%) and the check-up included an electrocardiogram (98%), a Holter monitoring (56%) and/or an echocardiography (71%). The preferred indication was supraventricular rhythm disorders (95%) and mostly atrial fibrillation (63%). A small proportion of coronary patients (7%) and of patient suffering from cardiac insufficiency (4%) was found. Flecainide was prescribed with a median posology of 150 mg per day, mostly as LP form (64%). Overall, the indications specified in the summary of product characteristics were respected in 90% of the cases, the contraindications in 91% of the cases and the patient follow-up was appropriate in 99% of the cases. In conclusion, the study showed that the prescription's conditions of flecainide in France complied with the summary of product characteristics data for most of the prescribing physicians with a respect of the indications, contraindications and management recommendations in 84% of the cases.

Little information is available as regards risk factor control and use of secondary prevention medications in elderly populations with documented atherosclerotic disease. The ELIAGE-MG survey included 3247 patients with cardiovascular disease seen in ambulatory practice. Overall, both the control of risk factors and the use of secondary prevention medications was suboptimal in these patients. However, those having consulted a cardiologist at any time during the previous year had better control of risk factors (and particularly LDL cholesterol and smoking) and were more often prescribed recommended secondary prevention medications.

The in-hospital management and short- and long-term outcomes was assessed in 2 registries of consecutive patients admitted for acute myocardial infarction, 5 years apart, in France. The 2000 cohort was younger and with a less frequent history of cardiac diseases, but was more often diabetic and with anterior infarcts. Time to admission was actually longer in 2000 than in 1995 (median 5.25 hours vs 4.00 hours). Overall, reperfusion therapy was used in 43% of the patients in both registries. However, the use of reperfusion therapy increased from 1995 to 2000 in patients admitted within 6 hours of symptom onset (64 vs 58%), with an increasing use of primary angioplasty (from 12 to 30%). Five-day mortality significantly improved from 7.7 to 6.1% (p0.03) and one-year survival was also less in the most recent period (85 vs 81%, p0.01). Multivariate analyses showed that the period of inclusion (2000 vs 1995) was an independent predictor of both short- and long-term mortality in patients admitted within 6 hours of symptom onset. Thus, in the real world setting, a continued decline in one-year mortality was observed in patients admitted to intensive care units for recent acute myocardial infarction, especially for patients admitted early. This goes along with a shift in reperfusion therapy towards a broader use of primary angioplasty, and with an increased use of the early prescription of recognised secondary prevention medications.

Several studies underlined the worse prognosis of myocardial infarction (MI) among patients with peripheral arterial disease (PAD). We sought to describe the presentation and management modalities of a cohort of PAD patients presenting an acute MI, compared to those without PAD.The USIC 2000 registry, a nationwide database on all patients admitted to a CCU for an acute MI48 hours in France in November 2000 was used for this study.Among the 2311 patients included, PAD was reported in 215 subjects (9.3%). In multivariate analysis, the following factors were positively related to the presence of PAD (Por = 0.05): age75 y (OR = 2.3), diabetes (OR = 2.0), hypertension (OR = 1.4), active smoking (OR = 4.6), renal failure (OR =3.1), and treatments with antiplatelets (OR = 3.9), anti-vitamin K (OR = 1.9), statins (OR = 1.7) and low molecular weight heparins (OR = 6.8). By introducing the data concerning the arrival in CCUs in the model, the following factors were also significantly more frequent among PAD patients: male sex (OR = 1.6), past history of coronary artery disease (OR = 2.2), left bundle branch block (OR = 1.8) and late management6 hours (OR = 1.4). Conversely, ST-segment elevation was less frequent (OR = 0.7). When the CCU stay data were introduced in the model, a lower rate of coronary stenting (OR = 0.7) and betablockers use within 48 hours of admission (OR = 0.6) were noted.Beyond the presence of PAD per se, several particularities do exist, especially the coexistence of a high number of pejorative factors and an under-utilization of treatments presenting prognostic benefits.

A large proportion of patients with a ST-elevation acute coronary syndrome do not receive reperfusion therapy. In order to contribute to a better understanding of the clinical decision making process, we analyzed which factors are associated with the application of reperfusion therapy.From the Euro Heart Survey of Acute Coronary Syndromes I, 4,260 patients with ST-elevation acute coronary syndrome were selected for the current analysis, of which 1,539 (36%) patients received fibrinolysis and 904 (21%) primary percutaneous coronary intervention (PCI). The analysis contained 32 variables on demographics, medical history, admission parameters and reperfusion therapy.A short pre-hospital delay, arrival in a hospital with PCI facilities, severe ST-elevation, and participation in a clinical trial were the strongest predictors for receiving reperfusion therapy. Primary PCI was more likely to be performed than fibrinolysis in patients with a long pre-hospital delay, arriving in a hospital with PCI facilities, not participating in a clinical trial, and with at least one previous PCI.Hospital facilities and culture, pre-hospital delay and infarction size play a major role in management decisions regarding reperfusion therapy in ST-elevation acute coronary syndrome. This analysis indicates which factors require special attention when implementing and reviewing the reperfusion guidelines.

The ANCOR survey was designed to assess the evolution of the prescription of secondary prevention medications in patients undergoing myocardial revascularisation, from the preoperative period to 3-6 months post-procedure. A total of 1535 patients (mean age: 64 years, 79% men), 321 after coronary surgery and 1214 after percutaneous coronary intervention, were included. Of them 37% still described anginal symptoms (Canadian class 1 in 80% of them); 38% still had elevated blood pressure (or = 140 mm HG systolic and/oror = 90 mmHg diastolic) and 27% of previous smokers still smoked after the procedure. All classes of secondary prevention medications were more often prescribed after than before intervention, antiplatelet agents (63.5 to 89%), beta-blockers (53 to 73.5%), statins (51 to 3%), ACE inhibitors (27 to 39%) and nicorandil (14 to 21%). Factors associated with the prescription of the different classes of medications were both expected (such as hypertension for ACE inhibitors or statins in hyperlipidemic patients) or unsupported by scientific evidence (less beta-blockers in diabetic patients). Overall this survey shows that myocardial revascularisation constitutes a key point in the management of patients with coronary disease, and that cardiologists consider that treatment of the atherosclerotic process is as important as the treatment of focal coronary artery stenoses.

More and more elderly people are hospitalised with myocardial infarction. Little is known on their pre-hospital management. In 2001 and 2002, 105 patients aged 80 years or more with suspected ST elevation infarction were managed by the mobile intensive care unit system of the SAMU de Paris-Necker. Diagnosis of infarction was confirmed in 92 (88%). Over 60% of the patients were women. Median time delay from symptom onset to call to the emergency service was 127 minutes, longer in nonagenarians (175 vs 101 minutes). Prehospital use of aspirin was 81% and 39% received an intravenous bolus of heparin. A reperfusion strategy was decided in only 30% (primary PCI: 23/26). One-month mortality was 21% and was related to older age, time when the call to the Samu was made, and absence of current smoking. Overall, the prehospital management of very elderly patients with suspected ST elevation infarction appears far from optimal.

Limited data are available regarding drug prescription for cardiovascular prevention in elderly patients seen by cardiologists.The ELIAGE survey was conducted in France between March and September 2003 among 507 cardiologists. 1952 consecutives elderly patients (or = 70 years old) were enrolled. Mean age was 76 years, 40% were between 70 and 74, and 26% were more than 80. Sixty-two of patients were men. Sixteen percent of patients had no history of cardiovascular disease but presented at least one of major cardiovascular risk factor: hypertension (91%), hyperlipemia (58%), diabetes (28%), and/or smoking (6%). Eighty-four percent had a known history of occlusive, atherosclerotic vascular disease: coronary heart disease in 76%, peripheral artery disease in 17%, and prior stroke or transient ischemic attack in 13%. Heart failure was observed in 21%.The rates of prescription in the overall survey population were respectively 68% for antiplatelet agents, 67% for lipid lowering drugs (of which 85% were on a statin), 51% for beta-blockers and 41% for angiotensin converting enzyme inhibitors. Among patients with coronary heart disease, prescription rates were 42% for ACE-inhibitors, 58% for beta-blockers, 76% for antiplatelet agents and 72% for lipid-lowering agents, 85% of whom received a statin. The ELIAGE survey shows a high prevalence of persistent dyslipidemia, with 46% of patients having a LDL-cholesterol equal to or greater than 1.25 g/l and 15%or = 1.60 g/l. Despite lipid-lowering therapy, LDL-cholesterol remained equal to or greater than 1.25 g/l in 40% of treated patients andor = 1.60 g/l in 13%. Blood pressure control was not better with 61% of patients having systolic blood pressureor = 140 mmHg and 21%or = 160 mmHg. In multivariate analysis, increase was inversely associated with the prescription of lipid-lowering therapy.The ELIAGE survey in France shows the persistence of poor control of modifiable risk factors among elderly patients seen by cardiologists. Both primary and secondary cardiovascular prevention appear to be unsatisfactory. Improved utilisation of proven therapeutic classes may lead to improvements in cardiovascular prevention.

We assessed the in-hospital management and short- and long-term outcomes of two series of patients admitted for acute myocardial infarction, 5 years apart, in France. The most recent cohort was younger and with a less frequent history of cardiac diseases, but was more often diabetic and with anterior infarcts. Five-day mortality significantly improved from 7.7% to 6.1% (P0.03) and 1-year survival was also less in the most recent period (15% versus 19%, P0.01). Multivariate analyses showed that the period of inclusion (2000 versus 1995) was an independent predictor of both short- and long-term mortality. In analyses restricted to the patients who were alive by day 5, initial treatment with statins was associated with a 38% decrease in the risk of death at 1 year. Likewise, in patients with left ventricular ejection fractionor = 35%, the early prescription of ACE inhibitors was associated with a 41% reduction in the risk of 1-year mortality. Thus, in the real world setting, a continued decline in 1-year mortality is observed in patients admitted to intensive care units for recent acute myocardial infarction. This goes along with a shift in reperfusion therapy towards a broader use of coronary angioplasty and with an increased use of the early prescription of recognised secondary prevention medications.

To compare the results of two readings of Intima Media thickness (EIM): one performed during measurement by the cardiologist, the other by a technician in a reading unit. To evaluate the consequences of these readings on the principal criterion of a study conducted into cardiovascular risk (RCV) for hypertensives followed up in ordinary medical practice.The EIM was measured in 991 hypertensives with the aid of the M'Ath program by cardiologists specially trained in the technique, within the framework of a study aimed at evaluating the RCV according to the WHO/ISH classification. The re-reading of source data by a reference centre was performed with the same program.The analysis was performed in 973 patients after eliminating duplicates and missing values (2%). The average cardiologist value of EIM was 0.761 +/- 0.168 mm, after centralised reading it was 0.743 +/- 0.128 mm. The difference between the measurements was -0.020 +/- 0.150 (p0.0001). According to the OMS/ISH classification, the presence of a vascular condition categorizes a hypertensive as being at "high risk" of a cardiovascular complication occurring. The calculation of RCV was performed by taking a value of EIM0.7 mm and/or presence of a plaque to define a vascular condition. The appreciation of risk was identical for the subjects at low risk and at very high risk. There was a shift from medium risk towards high risk: General Medicine 15%, Cardio 49%, after re-reading 68%.Despite the simplicity and the good inter observer reproducibility of the measurement of EIM by the M'Ath program, centralization of the reading is recommended during clinical trials.

Ticlopidine or clopidogrel combined with aspirin decrease major cardiac events (Mace) after PTCA with stent implantation. It has not be proven yet that pretreatment by T or C was superior to conventional post-treatment, especially in unstable patients. The aim of the present study was to determine the influence of thienopyridine pretreatment on the risk of Mace (death, Q wave myocardial infarction, need for repeat PTCA or surgery, angina recurrence, stent thrombosis) during the hospitalization period in a population prospectively included in 2 multicentre registries of patients undergoing placement of a S670 or S7 stent (Medtronic) implanted in native coronary arteries (or = 3.0 mm). Among the 2929 patients included into the registries, 1205 had unstable angina (41%). 50.2% of the patients were pretreated by T or C (T = 15.7%, C = 34.5%); 85.5% received aspirin before the procedure; definition of pretreatment was the administration of drug at least 6 hours before stent implantation. GPIIb-IIIa antagonists were administered in only 13.9% of patients. Mace were observed in 2% of the patients. Factors correlated with Mace by univariate and multivariate analyses were: age73 years (RR: 2.37; 95% CI: 1.05-5.36, P0.037), previous myocardial infarction (RR: 2.56; 95% CI: 1.08-6.11, P0.034), pretreatment by T or C (RR: 0.389; 95% CI: 0.16-0.95, P0.038). In patients who did not receive GPIIb-IIIa antagonists, age73, and pretreatment by T or C were the only independent predictors of Mace.

Prospective, randomised trials are the key to evidence-based medicine. They have brought considerable progress to the field of cardiology. They have, however, methodological constraints that result in the inclusion of only a small proportion of patients presenting with a given disease. In contrast, registries include all patients, without any selection, and therefore reflect everyday practice in the "real world". They are the key to epidemiological data, but they can also be used to tackle questions or issues that are unresolved by randomised trials. Both approaches are complementary and should be used to define the optimal management of patients. Lessons derived from registry data in acute coronary syndromes in the recent past in France are presented.

The use of cardiovascular secondary prevention medications in patients with acute coronary syndromes was compared in 4 sequential observational surveys carried out in France from 1995 to 2000. The Usik 1995 and Usic 2000 surveys included patients admitted for acute myocardial infarction, while the 2 Prevenir surveys (1998 and 1999) assessed the medications prescribed in patients with acute coronary syndromes. Antiplatelet agents were prescribed in 91% of the patients in 1995, 93% in 1998 and 1999 and 96% in 2000; for beta-blockers, the respective figures were: 64%, 68%, 75% and 76%. For ACE-Inhibitors, the figures were: 46%, 41%, 41% and 50%. For statins, the prescription increased from 10% to 36%, 59% and 64%. In 1995, 8% of the patients received both antiplatelet agents, beta-blockers and statins (4% of them also had an ACE-Inhibitor); in 2000, the respective figures were 53% and 27%. The results of the recent trials of secondary prevention medications have had a considerable impact on real-life practice in France during the late 1990s.

Three cases reports illustrate the concept of beating heart cardiac surgery and its advantages regarding the prevention of arterial emboli.

The role of early reperfusion therapy at the acute stage of myocardial infarctus in elderly patients is debated. The aim of this study was to analyze the prognostic role of reperfusion with i.v. thrombolysis or primary PTCA in the nationwide USIK database, which prospectively included all pts admitted to a CCU for an AMI48 hours in France in November 1998. For the purpose of the present study, only patients admitted within 24 hours of AMI and with one-year follow-up available were included. Of the 1838 patients included, 785 were70 years-old, of whom 225 (29%) had early reperfusion therapy with thrombolysis (N = 173) or primary PTCA (N = 52). Patients treated with early reperfusion had a baseline profile that differed substantially from that of patients treated conventionally: women (31% vs 50%, p0.001), admission within six hours of symptom onset (84% vs 55%, p0.001), history of systemic hypertension (48% vs 60%, p0.002), stroke (5% vs 11%, p0.01), peripheral arterial disease (8% vs 18%, p0.001); congestive heart failure (5% vs 20%, p0.001) or previous MI (12% vs 25%, p0.001), more anterior location of current MI (40% vs 28%, p0.002). Overall one-year Kaplan-Meier survival was 78% for patients with versus 64% for those without reperfusion therapy (p0.01). In patients with Q wave myocardial infarction, Cox multivariate analysis showed that reperfusion therapy was an independent predictor of survival (RR 0.66; 95% Confidence Interval: 0.45-0.96), along with age, anterior location and history of congestive heart failure. Therefore, data from this large "real life" registry indicate that reperfusion therapy with either thrombolysis or primary PTCA is associated with improved one-year survival in patients over 70 years of age.

The difficulty in controlling hypertension in coronary patients has been underlined. The aim of the study was to assess blood pressure profile (BP) at hospital discharge in a large population of survivors of an acute coronary syndrome.An observational study was conducted in France in 77 cardiological centers. The medical records of all patients admitted in these hospitals on January 1998 for a myocardial infarction or unstable angina and who survived were studied. Clinical characteristics and BP at hospital discharge were recorded. Patients with blood pressureor = 140/90 mmHg were considered as uncontrolled hypertensives (HT).Data were available in 1327 of the 1394 patients recruited: at hospital discharge, 344 patients (25.9%) were controlled and 431 (32.4%) were uncontrolled hypertensives. Among these patients, 406 (94.1%) had systolic blood pressureor = 140 mmHg, 139 (32.2%) had diastolic blood pressureor = 90 mmHg and 292 patients (67.7%) had systolic blood pressureor = 140 mmHg and diastolic blood pressure90 mmHg. Pulse pressure in controlled hypertensives (51.02 +/- 10.93 mmHg) was quite similar to that in normotensives (47.81 +/- 9.84 mmHg) whereas pulse pressure was significantly higher in uncontrolled hypertensives (65.86 +/- 13.29 mmHg).At hospital discharge after a coronary event, arterial hypertension is uncontrolled in 32.4% of patients mainly because of poor systolic blood pressure control. Achieving normal blood pressure throughout the hospitalisation should improve long term blood pressure control, reduce pulse pressure and improve the prognosis in this high risk population.

The aim of this study was to evaluate the distribution and hospital treatment of cardiovascular risk factors in coronary patients. A transverse observational study was carried out in 77 cardiological centres throughout France. All patients with a history of myocardial infarction or of unstable angina during the month of January 1998 were enrolled. The clinical features of 1334 patients (71.4% men, 746 myocardial infarction, 588 unstable angina) on hospital admission were analysed. The prevalence of smoking, dyslipidaemia, hypertension and obesity was 49, 45, 42, 19 and 11% respectively in the men and 17, 46, 63, 23 and 10% respectively in the women. The number of treatable risk factors slightly decreased in the oldest age group. The prevalence of hypertension increased with age whereas smoking and dyslipidaemia decreased in both men and women. Obese and diabetic patients had more risk factors than the others. A little less than half of patients with dyslipidaemia were under no preventive measures (diet and/or lipid-lowering drugs) and 40% of men with a previous history of coronary artery disease continued to smoke. The authors conclude that men over 85 and women over 75 years of age have fewer risk factors than other age groups and the type of risk factor varies with age. The treatment of dyslipidaeamia and smoking is still inadequate and should be improved.

Patients with acute myocardial infarction (AMI) who do not receive early reperfusion therapy are at high risk of reinfarction or death, and the efficacy and safety of antithrombotic therapy in this group of patients has not been evaluated. Enoxaparin is a low-molecular-weight heparin (LMWH) that has previously been shown to reduce the incidence of ischemic events in patients with unstable angina or non-Q-wave MI. The principal aims of the TETAMI study are to investigate the efficacy and safety of treatment with enoxaparin or tirofiban (a glycoprotein IIb/IIIa receptor antagonist) alone or in combination for 2 to 8 days in patients with AMI who are not eligible for early reperfusion therapy. In this 2 by 2 factorial design study approximately 900 patients will be randomly assigned, in a blinded manner, to one of four treatments: enoxaparin alone, enoxaparin plus tirofiban, unfractionated heparin (UFH), or UFH plus tirofiban, with appropriate matched placebos. The primary end point is the composite of death, recurrent AMI, and recurrent angina, analyzed at 30 days after AMI. The design and methods of the TETAMI study are described in this article.

The aim of this study was to evaluate the risks and benefits, immediate and at long term, of coronary angioplasty associated with stent implantation in patients with severe left ventricular dysfunction. It was a retrospective study in which all patients with left ventricular ejection fractions 35% who underwent angioplasty between December 1994 and January 1998 were included. Seventy eight patients with an average ejection fraction of 29 +/- 6% who were haemodynamically stable were retained, excluding acute myocardial infarctions and cases of cardiogenic shock. The population was mainly masculine (6(men and 13 women) with a mean age of 65 +/- 11 years. The primary success rate was 97%. The loss of a collateral branch during the procedure, causing a non-Q wave infarction and the impossibility of implanting the stent at the desired site in another patient, were the only two failures. Hospital mortality was nil. The mean follow-up period was 450 +/- 290 days; long-term mortality was 17%. All deaths were of cardiovascular origin. The probability of survival at 6 months, 1 year and 800 days, was 88, 85 and 75% respectively. The good initial results were not maintained at long-term, but this could not be attributed to restenosis or to the pre-existing left ventricular dysfunction.

The transmembrane sodium/hydrogen exchanger maintains myocardial cell pH integrity during myocardial ischemia but paradoxically may precipitate cell necrosis. The development of cariporide, a potent and specific inhibitor of the exchanger, prompted this investigation of the potential of the drug to prevent myocardial cell necrosis.A total of 11 590 patients with unstable angina or non-ST-elevation myocardial infarction (MI) or undergoing high-risk percutaneous or surgical revascularization were randomized to receive placebo or 1 of 3 doses of cariporide for the period of risk. The trial failed to document benefit of cariporide over placebo on the primary end point of death or MI assessed after 36 days. Doses of 20 and 80 mg every 8 hours had no effect, whereas a dose of 120 mg was associated with a 10% risk reduction (98% CI 5.5% to 23.4%, P=0.12). With this dose, benefit was limited to patients undergoing bypass surgery (risk reduction 25%, 95% CI 3.1% to 41.5%, P=0.03) and was maintained after 6 months. No effect was seen on mortality. The rate of Q-wave MI was reduced by 32% across all entry diagnostic groups (2.6% versus 1.8%, P=0.03), but the rate of non-Q-wave MI was reduced only in patients undergoing surgery (7.1% versus 3.8%, P=0.005). There were no increases in clinically serious adverse events.No significant benefit of cariporide could be demonstrated across a wide range of clinical situations of risk. The trial documented safety of the drug and suggested that a high degree of inhibition of the exchanger could prevent cell necrosis in settings of ischemia-reperfusion.

The predictive value of several diagnostic strategies after myocardial infarction was assessed in 178 patients (mean age 55 +/- 9 years) treated medically after a primary Q wave myocardial infarction. Within 6 weeks of onset of symptoms the authors performed exercise stress test coupled with Thallium 201 scintigraphy, isotopic left ventriculography and conventional coronary angiography with ventriculography. The average left ventricular ejection fraction was 45 +/- 12%. Two non-invasive diagnostic strategies with and without results of scintigraphy and two invasive strategies with and without ventricular volumes were studied. The average follow-up period was 58 +/- 22 months. Sixteen cardiac deaths occurred. Multivariate Cox analysis showed that, in contrast to left ventricular volumes, coronary angiography did not provide additional prognostic value compared with the non-invasive model with Thallium scintigraphy and did not appear to be essential in terms of predictive value in this population. Moreover, the size of reversible defect on Thallium scintigraphy was an independent predictive factor of cardiac death and provided additional and independent prognostic information in the non-invasive and invasive strategies. Therefore, the reduction of residual ischaemia by coronary revascularisation could improve the long-term prognosis after myocardial infarction.

Sildenafil (Viagra), an inhibitor of phosphodiesterase 5, has a powerful vasodilatory effect on the corpus cavernosa. An evaluation of coronary risk is necessary before its prescription in order to answer two questions: does taking this drug expose the patient to any special risk? Does the return to sexual activity itself carry any risk? Sildenafil is associated with a slight decrease in systolic (10 mmHg) and diastolic (7 mmHg) blood pressure which does not seem to be accentuated by the concommittant use of antihypertensive drugs. The co-administration of nitrate derivatives (before or after taking sildenafil) causes potentially dangerous falls in blood pressure (on average 40 mmHg for the systolic blood pressure). Co-administration of sildenafil and NO-donors is formally contra-indicated. The safety of sildenafil has been shown to be satisfactory in clinical trials: in particular, the risk of myocardial infarction is no greater in treated patients. Sexual activity is a generally moderately intense physical exercise and only rarely causes myocardial infarction. In practice, in patients without known coronary artery disease, the clinical history should be sufficient to determine whether the return of sexual relations is possible without risk. In known cardiac patients, sildenafil is contra-indicated in unstable situations; in stable coronary disease, it would seem wise to take advantage of the annual exercise stress testing to make sure of the absence of ischaemia on effort. In all cases, the patient must be warned that co-administration of nitrate derivatives is an absolure contra-indication to sildenafil treatment.

The purpose of this study was to determine whether antianginal medications modify the prognostic significance of exercise single photon emission computed tomography (SPECT) ischemia.Antianginal medications (especially beta-adrenergic blocking agents) limit exercise SPECT ischemia, but it is not known whether such medications also modify the prognostic effect of exercise SPECT ischemia.We included 352 patients with coronary heart disease, who had exercise Tl-201 SPECT and coronary angiography, and who were initially treated medically. Survival Cox models were applied in patients for whom classes of antianginal medications taken at exercise SPECT were the same as those prescribed for follow-up (GI; n = 136), and in patients for whom new classes of antianginal medications, including beta-blockers (GII; n = 79) or not including beta-blockers (GIII; n = 113), were added for follow-up.During a mean 5.3+/-1.6 years of follow-up, 45 patients had cardiac death or myocardial infarction. Variables reflecting necrosis (irreversible defect extent, left ventricular ejection fraction) and those from coronary angiography provided equivalent prognostic information in the three groups. In contrast, the SPECT variable reflecting ischemia (reversible defect extent), which provided comparable prognostic information in GI (p = 0.005) and GIII (p = 0.004), lost its prognostic significance (p = 0.54) in GII, and was associated with a lower relative risk in GII than in GI or GIII (both p0.05).In patients with coronary heart disease, the introduction of antianginal medications, when including beta-blockers, appears to have a favorable effect on the deleterious prognostic effect of exercise ischemia.

The initial phase of the epidemiological USIK study has recensed data concerning 2,563 patients admitted to hospital for acute myocardial infarction. The second phase of this study has documented the 1 year survival of 2,152 patients (84%). The population comprised 1,533 men and 619 women with a mean age of 67 years. Severe left ventricular dysfunction (LVEF35%) was observed in 18% of patients and clinical signs of cardiac failure were present in 35% of patients in the first 5 days of infarction. The mortality was 8.2% at 5 days, 13.2% at 28 days and 19.5% at one year. In multivariate analysis, the principal predictive factor of mortality at 1 year was age (RR = 1.06, p = 0.0001): the mortality increased by 6% per year of age. In survivors 5 days after the onset of infarction, the 1 year prognosis was significantly correlated with age (RR = 1.05, p = 0.0001) and with cardiac failure (LVEF: RR = 1.57, p = 0.0001) and Killip class (RR = 1.66, p = 0.0001). The prescription of an ACE inhibitor or a betablocker in the first 5 days of infarction was associated with a reduction in 1 year mortality of 27% (p = 0.04) and 37% (p = 0.01) respectively. In conclusion, this study has determined the features of patients admitted to the Intensive Care Unit for acute myocardial infarction in France and to identify the factors influencing 1 year survival.

Sinus tachycardia is frequent after cardiac surgery and this tachycardia is probably due to changes of the autonomic nervous system. The objective of this study was to evaluate the changes possibly induced by cardiac surgery, by studying sinus variability (SV) during a 24-hour Holter monitoring. The examination was performed in 28 patients who had undergone cardiac surgery 1 to 6 weeks previously. These patients had no alteration of left ventricular function, or any causes likely to modify SV and they had a normal postoperative course. Their results were compared to those of 4 subjects developing a postoperative complication (1 case of ventricular tachycardia and 3 cases of resuscitated cardiac arrest). The results were also compared to those of 24 age-matched adult controls without heart disease (control group). The study of SV included temporal and spectral analysis of SV with measurement of the standard deviation of normal RR intervals (SD), mean heart rate (HR), percentage of RR intervals differing by more than 50 m/sec from the adjacent interval (pNN50), coefficient of variability (CV) (SD/RR), square root of the differences between successive RR (rMSSD), spectral properties of low frequencies (LF) and high frequencies (HF) and the fractionated spectral property (LF/HF).(see tables, page 151 and 152). An alteration of SV was therefore observed in the surgical group, and lasted 4 to 6 months after surgery. No difference was observed between subjects without cardiac events and those presenting a cardiac event.cardiac surgery decreases all parameters of SV during the first few postoperative months. Certain unexpected cardiac accidents during this period could be explained by these changes.

Determine early and mid-term mortality in diabetic patients with myocardial infarction and ascertain whether diabetes is an independent prognosis factor.All patients admitted to an intensive care unit within 48 hours of the first signs of myocardial infarction were included in the study. Diabetic status was recorded at admission. Early mortality (5 day) and 1-year mortality was compared between diabetic and non-diabetic patients. Multivariate analysis was used to determine the predictive value of diabetic status as an independent factor.2527 patients, including 440 diabetics (17%) and 2087 non-diabetics (83%) were followed at 5 days; 2125 patients, including 364 diabetics (17%) and 1761 non-diabetics (83%) were followed to 1 year. Diabetes was more frequent in older patients and in women. Mortality in diabetic patients was higher than in non-diabetics. At 5 days, mortality was 10.4% versus 17.6% (p0.001). Multivariate analysis did not confirm diabetic status as an independent risk factor for death at 5 days. Inversely, at 1 year, diabetic status was an independent risk factor (RR = 1.4; 95% CI = 1.1 -1.8; p = 0.004).Diabetes is associated with poor prognosis after myocardial infarction. After correction for other risk factors, diabetes is an independent risk factor which must be taken into account when managien after myocardial infarction.

The aim of this study was to determine whether advances in angioplasty techniques have improved results in multiple vessel coronary disease and to compare present results with those reported in randomised trials comparing angioplasty and surgery. The hospital results of two cohorts of multivessel coronary patients treated by angioplasty during two different periods were compared (group 1: 1990-1991. group 2: 1994-1995). The first period corresponded to the inclusion period of randomised trials comparing surgery and angioplasty. The patients in group 2 (n = 449) were older than those in group 1 (n = 424), had more triple vessel disease, more severe angina and more previous angioplasty attempts. Moreover, there were more cases of unfavourable lesions. Nevertheless, the clinical success rate was high in group 2 (92% vs 84%; p0.001) and the major complication rate (death, myocardial infarction or emergency bypass surgery) was lower (2.9% vs 6.1%; p = 0.02). The main technical difference between the two periods concerned the use of coronary stents (12% vs 8%; p0.001). The fact of being in group 2 was identified by multivariate analysis as an independent predictor for clinical success and a lower major complication rate. The authors conclude that, since the publication of randomised trials comparing angioplasty with coronary surgery, the hospital results of angioplasty have significantly improved. This should be taken into account in considering the clinical applications of the results of these trials.

Fluoroscopic and cineradiographic procedures expose patients undergoing coronarography to high doses of ionizing irradiation.We report four cases of radiodermitis following cardiac catheterization. A 69-year-old man developed a radio-induced ulceration on the left scapular region in 1991 which required excision with skin graft. He had undergone 3 coronarographies and 2 angioplasties from 1989 to 1991. In 1992, a 59-year-old women developed a hard dorsal lesion with central ulceration and scar formation requiring excision and graft. From 1990 to 1992, she had undergone two coronary dilatations with angioplasty during one procedure. An atrophic necrotic wound situated under the right nipple developed in a 63 year old man. Excision with flap reconstruction was performed in 1993, two years after an unsuccessful angioplasty then two-vessel bypass. In a fourth case, a 52 year-old woman developed a telangiectasic ulceration on the right breast in 1990. The diagnosis of radio-induced dermitis was confirmed in 1996 and the patient was treated by excision. She had had three angioplasties in 1989.Four other cases of radio-induced dermatitis following cardiac catheterism have been reported in the literature since 1996. Six other cases were also recently reported in France. All of these patients had undergone coronarography with transluminal coronary angioplasty. Besides coronarography, irradiation exposure is greatest for guide and balloon insertion required for dilatation procedures. Angioplasty is particularly dangerous because the irradiation beam is focused on the stenosis while the entire coronary network is concerned for coronarography. In most cases of radio-induced dermatitis following cardiac catheterism, the diagnosis is usually evident from the clinical context and the localization of the coronary lesion. In many cases however, the long delay to onset may make diagnosis a difficult task. In addition, the radiation dose delivered to the skin during cardiac procedures is not measured.

A national epidemiological study undertaken in November 1995 recensed the data of 2563 patients admitted to 373 Intensive Care Units for acute myocardial infarction. There were 1827 men and 736 women with an average age of 67 years. Seventeen per cent of patients had left ventricular ejection fration (LVEF)or = 35%. The mortality rate at 5 days was 7.7%. Clinical heart failure (Killip1) was observed in 34.4% of patients. 63% of patients were admitted before the 6th hour. Forty-six per cent of patients underwent early revascularisation by thrombolysis and/or angioplasty. The most widely used drugs in the first 5 days were heparin (96%), aspirin (89%), betablockers (65%), and angiotension converting enzyme inhibitors (46%). The influence of region on the demographical features, morbidity, mortality and therapeutic practice was studied. France was divided into 6 regions. In the Centre, the patients were older, with increased morbidity and mortality compared with the national average. Patients in the North East were similar and had a higher incidence of obesity. In the Ile de France, patients were generally younger with a higher incidence of tobacco consumption and their infarcts were generally less severe. Finally, in the South East, the mortality was particularly low. In multivariate analysis living in this region was good prognostic factor whereas low LVEF (or = 35%) and ageor = 65 years were poor prognostic factors. This study, for the first time in France, describes the clinical features of myocardial infarction admitted to the Intensive Care Unit with respect to criteria of severity (LVEF, Killip) and region of origin of the patients. Its confirms large regional variations in the severity of acute myocardial infarction.

The study of heart rate variability is a new means of assessing autonomic nervous system function and the risks of cardiac and sudden death in patients with advandec cardiac disease. The aim of this study was to analyse changes in heart rate variability in the hours preceding cardiac death and just before its occurrence. Seventeen subjects aged 78.5 +/- 10 years, with advanced cardiac disease responsible for a reduction of left ventricular ejection fraction below 40%, died during Holter ECG recording. Ten died of ventricular fibrillation, 5 of bradycardia and 2 of non-rhythmic causes. General analysis of heart rate variability showed a decrease in all but 1 patient, the average standard deviation of normal RR intervals in subjects in sinus rhythm being 53 +/- 14 msec and the fractioned spectral power (low frequency/high frequency power) being 1 +/- .07. The change in heart rate variability did not allow prediction of the mechanism of death: the mean heart rate only increased before death in 3 of the patients with an ischaemic component in the hours before death, the indices of vagal tone were very low in the majority of patients and, just before death, a disequilibrium between the spectral powers with a sudden increase in LF/HF ratio of 10 of the 17 patients, irrespective of the cause of death, appeared. In conclusion, a decrease in heart rate variability was observed in all cases but did not predict the mechanism of death. Just before death occurred, some patients, especially those with acute ischaemia, showed a sudden change in the indices of heart rate variability indicating a terminal vaso-sympathetic disequilibrium.

Programmed atrial stimulation is a technique increasingly used to assess different pathologies but the reproducibility of the results is totally unknown. The aim of this study was to determine its reproducibility. Two electrophysiological studies were undertaken without antiarrhythmic therapy in an interval of one to three months (average 18 months) in 48 patients. The programmed atrial stimulation used 1 and 2 extrastimuli delivered in sinus rhythm and then three paced rhythms (sinus cycle -10%, 600 ms, 400 ms). Twenty-one patients had documented atrial arrhythmias (atrial fibrillation n = 13, flutter n = 3 or tachycardia n = 5) (group 1) and the 27 other patients had no spontaneous arrhythmias (group II). In group I, clinical tachycardial was reproduced in 18 patients during the initial stimulation procedure. During the second investigation, 17 remained inducible and in the 3 in whom stimulation was negative, it remained so in 2 of the cases. The reproducibility was therefore 90%. In group II, 12 patients had inducible sustained (for over 1 minute) tachycardia during the first procedure (44%) but this only remained inducible in 6 patients. In the other 15 subjects, stimulation was negative during the first procedure but 7 of them had inducible tachycardial during the second procedure. The reproducibility of the technique was therefore only of 52%. The authors conclude that the reproducibility of programmed atrial stimulation in patients with documented spontaneous paroxysmal arrhythmias is excellent. However, the reproducibility is mediocre in subjects without spontaneous arrhythmias and the induction of tachycardial in this group of patients should be interpreted with caution given the variability of the response to programmed atrial stimulation.