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Introduction: Surgically treated acute type A aortic dissection (ATAAD) patients are often restricted from physical exercise due to a lack of knowledge about safe blood pressure (BP) ranges. The aim of this study was to describe the evolution of early postoperative cardiac rehabilitation (CR) for patients with ATAAD., Methods: This is a retrospective study of 73 patients with ATAAD who were referred to the CR department after surgery. An incremental symptom-limited exercise stress test (ExT) on a cyclo-ergometer was performed before and after CR, which included continuous training and segmental muscle strengthening (five sessions/week). Systolic and diastolic blood pressure (SBP and DBP) were monitored before and after all exercise sessions., Results: The patients (78.1% male; 62.2 ± 12.7 years old; 54.8% hypertensive) started CR 26.2 ± 17.3 days after surgery. During 30.4 ±11.6 days, they underwent 14.5 ± 4.7 sessions of endurance cycling training, and 11.8 ± 4.3 sessions of segmental muscle strengthening. At the end of CR, the gain of workload during endurance training and functional capacity during ExT were 19.6 ± 10.2 watts and 1.2 ± 0.6 METs, respectively. The maximal BP reached during endurance training was 143 ± 14/88 ± 14 mmHg. The heart rate (HR) reserve improved from 20.2 ± 13.9 bpm to 33.2 ± 16.8 bpm while the resting HR decreased from 86.1 ± 17.4 bpm to 76.4 ± 13.3 bpm., Conclusion: Early post-operative exercise-based CR is feasible and safe in patients with surgically treated ATAAD. The CR effect is remarkable, but it requires a close BP monitoring and supervision by a cardiologist and physical therapist during training.

Background: Exercise training (ET) increases exercise tolerance, improves quality of life and likely the prognosis in heart failure patients with reduced ejection fraction (HFrEF). However, some patients do not improve, whereas exercise training response is still poorly understood. Measurement of cardiac output during cardiopulmonary exercise test might allow ET response assessment according to the different steps of oxygen transport., Methods: Fifty-three patients with HFrEF (24 with ischemic cardiomyopathy (ICM) and 29 with dilated cardiomyopathy (DCM) had an aerobic ET. Before and after ET program, peak oxygen consumption (VO 2peak ) and cardiac output using thoracic impedancemetry were measured. Oxygen convection (QO 2peak ) and diffusion (DO 2 ) were calculated using Fick's principle and Fick's simplified law. Patients were considered as responders if the gain was superior to 10%., Results: We found 55% VO 2peak responders, 62% QO 2peak responders and 56% DO 2 responders. Four patients did not have any response. None baseline predictive factor for VO 2peak response was found. QO 2peak response was related to exercise stroke volume (r = 0.84), cardiac power (r = 0.83) and systemic vascular resistance (SVR peak ) (r = -0.42) responses. Cardiac power response was higher in patients with ICM than in those with DCM (p < 0.05). Predictors of QO2 peak response were low baseline exercise stroke volume and ICM etiology. Predictors of DO 2 response were higher baseline blood creatinine and prolonged training., Conclusion: The analysis of the response to training in patients with HFrEF according to the different steps of oxygen transport revealed different phenotypes on VO 2peak responses, namely responses in either oxygen convection and/or diffusion., Competing Interests: Declaration of Competing Interest None, (Copyright © 2021 Elsevier B.V. All rights reserved.)

Secondary cardiovascular prevention strategies. Patients with a documented peripheral or coronary artery disease, subclinical atheroma, diabetes associated with target organ damage or a major risk factor or severe kidney failure have a risk of cardiovascular death above 10% in the next 10 years. They all should be helped to adopt a healthier life style and be prescribed a targeted polytherapy. Unless intolerant or contraindicated, an antiplatelet agent, a statin (whatever may be the initial LDL-cholesterol level) and a renin-angiotensin blocker should be prescribed for all patients. Especially important, a LDL-cholesterol target below 1.8 mM/l (70 mg/dl) or reduced by at least 50% of the initial level should be obtained. Significant other changes have recently occurred in the European guidelines, which are summarized in this article., Competing Interests: F. Ledru déclare n’avoir aucun lien d’intérêts.

Helping patients to engage in health care. Engaging in health care, be it preventive care, is a tough challenge for both patients and health care providers. Being threatened by the irruption of a chronic disease, or even by a hazard for his own health, every individual is seeking for a bearable daily living and tries to recover some autonomy and power upon his life. This long-standing process is actually a permanent endeavour to reconfigure beliefs and values, rebuild a new identity and learn how to cope with uncertainties. The role for all health care providers is to facilitate this complex process, using appropriate communication skills and pedagogic knowledge that we discuss in this article., Competing Interests: F. Ledru déclare n’avoir aucun lien d’intérêts.

Competing Interests: F. Ledru déclare n’avoir aucun lien d’intérêts.

Competing Interests: F. Ledru déclare n’avoir aucun lien d’intérêts.

Large subsets of patients admitted in cardiac rehabilitation centers are having a pacemaker, cardiac resynchronization (CRT) or implantable cardiac defibrillator (ICD). Cardiac rehabilitation for patients, mostly with heart failure, with implanted electronic devices as pacemakers or ICD is a unique opportunity not only to optimize the medical treatment, to increase their exercise capacity and improves their clinical condition but also to supervise the correct functioning of the device. CRT reduces clinical symptoms and increases slightly the exercise capacity. But in these patients, the clinical improvements are likely to be explained by both the enhancement of cardiac function induced by the device and by the improved peripheral (muscular and vascular) and cardiac effects of exercise. The additional expected gain by exercise in this population is between 14 to 25%. In patients implanted with an ICD, exercise training is safe, without increasing shocks or anti-tachycardia pacing therapy. The comprehensive cardiac rehabilitation combining exercise training and a psycho-educational intervention improves exercise capacity, quality of life, general and mental health. Nevertheless, further large scale studies was needed to evaluate the most appropriate management and demonstrate definitively the role of cardiac rehabilitation in this particular group of 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., (Copyright 2010 Elsevier Masson SAS. All rights reserved.)

Background: Erectile dysfunction (ED) is a frequent comorbid condition in men with coronary heart disease (CHD). Depressive mood is associated with adverse outcomes in CHD patients. The aim of this study was to explore the relationships between ED and depressive mood in CHD male patients., Methods: Eighty-five CHD male patients were given standardized questionnaires to assess ED, depressive mood, current anxiety, and Type-D personality (i.e. negative affectivity and social inhibition)., Results: A significant ED was found in 57.6% of the patients. Controlling for psychometric measures, CHD risk factors, and drugs, a significant ED was independently predicted by depressive mood, hypertension and, marginally, age., Conclusions: These results confirm the high prevalence of ED in CHD male patients. They suggest that ED in CHD male patients may be more strongly associated with depressive mood than with antihypertensive drugs. Because depressive mood is associated with adverse CHD outcomes and may require adequate treatment, clinicians should better search for depressive mood in CHD patients presenting with ED., (Copyright 2008 Elsevier Ireland Ltd. All rights reserved.)

Background: The cardiovascular effects of sulfonylureas (SU) in diabetic patients are controversial and it has been suggested that diabetic patients with acute myocardial infarction while on SU were at increased risk., Objectives: To assess the in-hospital outcome of patients with acute myocardial infarction according to the use of SU at the time of the acute episode., Methods: Of 443 intensive care units in France, 369 (83%) prospectively collected all cases of infarction admitted within 48 h of symptom onset in November 2000., Results: Among the 2320 patients included in the registry, 487 (21%) had diabetes, of whom 215 (44%) were on SU. Patients on SU were older and had a more frequent history of hyperlipidemia than those not receiving SU. Type and location of infarction were similar in the two groups, and there was no difference in Killip class on admission. In-hospital mortality was lower in patients on SU (10.2%) than in those without SU (16.9%) (p = 0.035). There was a trend toward less frequent ventricular fibrillation (2.3% vs 5.9%, p = 0.052). In two models of multivariate analyses, SU therapy was associated with decreased in-hospital mortality (model 1: relative risk: 0.44, p = 0.012; model 2: relative risk: 0.37, p = 0.020)., Conclusions: In this nationwide registry reflecting real-world practice, the use of sulfonylureas in diabetic patients was not associated with increased in-hospital mortality., (Copyright 2004 John Wiley & Sons, Ltd.)

Type 2 diabetes has reached epidemic proportions and an increasing proportion of patients with coronary artery disease (CAD) are diabetics. CAD in diabetics has specificities and, in particular, more extensive atherosclerosis; diabetic patients are also more frequently asymptomatic, with silent myocardial ischemia, which makes the diagnosis of CAD more difficult. In addition, diabetic patients with CAD have poorer outcomes than nondiabetics. The management of diabetic patients with CAD is based on intensive intervention on lifestyle and risk factors, together with the mandatory use of medications of proven benefit as regards secondary prevention in coronary patients: antiplatelet agents, statins, beta-blockers, and angiotensin-converting enzyme (ACE) inhibitors. Glycemic control is also essential; although the use of sulfonylureas has been controversial, there is now a vast amount of data suggesting a beneficial effect, in particular when agents more specific for the pancreatic adenosine triphosphate-dependent potassium (K(ATP)) channels are used. At the acute stage of myocardial infarction, the Diabetes mellitus, Insulin Glucose infusion in Acute Myocardial Infarction (DIGAMI) trial suggested a beneficial effect of insulin therapy prolonged for 3 months after hospital discharge; these data will have to be confirmed by larger intervention trials. Finally, the respective roles of coronary angioplasty and coronary surgery in diabetics are debated; a post hoc analysis of the Bypass Angioplasty Revascularization Investigation (BARI) trial data showed increased mortality in diabetics with multivessel CAD treated with angioplasty compared with surgery, but the results of the more recent trials using intracoronary stents appear more balanced; in this regard, the effects of drug-eluting stents, which dramatically decrease the incidence of re-stenosis, seem promising.

Purpose: In medical literature, primary pulmonary hypertension occurs in 0.5% of human immunodeficiency virus (HIV)-infected patients, irrespective of the stage of the HIV disease, and is more frequent in drug users. Plexogenic arteriopathy is the most frequent histological lesion., Methods: We retrospectively report on nine cases of primary pulmonary hypertension during HIV infection., Results: The subjects were four women and five men, mean age 38 years old. Four of them had been sexually contaminated and five had contracted the disease through intravenous drug use. At the time primary pulmonary hypertension was diagnosed, mean CD4 cell count was 234 +/- 217/mm3 and the viral load was low or undetectable. Primary pulmonary hypertension has been diagnosed an average of 7 months after the first cardiovascular clinical signs had started. Despite anti-coagulant (7/9 cases), vasodilatator (4/9 cases) and/or diuretic (7/9 cases) therapy, the progression of the disease quickly turned out to be negative (seven deaths)., Conclusion: Diagnosis of primary pulmonary hypertension should be considered when unexplained dyspnea occurs in an HIV-positive patient. At initial evaluation, alterations of hemodynamic parameters are usually less severe than during idiopathic primary pulmonary hypertension, but their progression is quicker and more severe, independent of the patient's immune status. Current data do not allow the determination of whether antiretroviral therapy is active in primary pulmonary hypertension evolution. Therapeutic evaluation with prostacyclin is currently being carried out. While the life expectancy of HIV-infected patients extends, primary pulmonary hypertension occurrence could increase and call for early diagnosis, thus allowing for specific care.

Objectives: The goal of this research was to study coronary atherosclerosis in patients with type 2 diabetes compared with patients without diabetes according to the new definition of diabetes advocated by the American Diabetes Association in 1997., Background: Patients with diabetes (fasting plasma glucose above 7.0 mM/L) have a higher risk of cardiovascular death. The correlation with the pattern and severity of their coronary atherosclerosis, especially in the new patients with "mild" diabetes (7.0 mM/L < or = fasting plasma glucose < 7.8 mM/L), remains unclear., Methods: A cohort of 466 patients undergoing coronary angiography but free of any previous infarction, coronary intervention and insulin therapy were prospectively recruited. Ninety-three had diabetes (fasting plasma glucose > 7.0 mM/L or hypoglycemic oral treatment). Five angiographic indexes were calculated to describe severity and extent of coronary atherosclerosis., Results: Overall, patients with diabetes had more diffuse coronary atherosclerosis, a greater prevalence of mild, moderate and severe stenoses and a two-fold higher occlusion rate than patients without diabetes, even after adjustment for age, gender, body mass index, hypertension, lipid parameters, smoking, family history of cardiovascular events and ischemic symptoms. Patients with "mild diabetes" had a coronary atherosclerosis pattern more similar to patients with normal fasting plasma glucose than to patients formerly defined as diabetic according to the World Health Organization criteria, except that they had a higher prevalence of <50% stenoses., Conclusions: In patients with type 2 diabetes, those with 7.0 mM/L < or = fasting plasma glucose < 7.7 mM/L have a slightly greater prevalence of mildly severe lesions that may partly explain their higher cardiovascular event rate.

Restenosis is the main limitation of percutaneous angioplasty, especially in vessels of small diameters such as the coronary arteries, the femoro-popliteal and tibial-peroneal arteries and the arterio-venous dialysis grafts. The extensive use of tents has not entirely prevented its occurrence, whereas treating in-stent restenosis gives even more uncertain results. Endovascular radiotherapy has emerged over the past few years as a promising approach to both prevent and cure it. The analogy between the tumour-like cellular proliferations observed in post-angioplasty restenosis and tumour processes prompted pioneering works to study the effect of ionizing radiations in animal models of arterial restenosis. The demonstrated feasibility, tolerance and efficacy of this approach lead to test this strategy in humans. The results of 3 recently presented randomized double-blind trials in the treatment of coronary in-stent restenosis have been so promising that endovascular brachytherapy might now be considered the treatment of choice in this indication. Other randomized trials are currently carried out to test whether endovascular brachytherapy may prevent restenosis in coronary and femoro-popliteal arteries as well as in hemodialysis shunts. In the present review, we describe the basics of the biological effects of ionizing radiations, the technical modalities to deliver endovascular radiations, our current knowledge about their effects on the vascular wall and the restenosis mechanisms, and the results of the first clinical studies. Finally, we address the remaining problems in the use of endovascular curietherapy and question the promises and challenges of its clinical application.

Objectives: We sought to make a prospective comparison of systematic stenting with provisional stenting guided by Doppler measurements of coronary velocity reserve and quantitative coronary angiography., Background: Despite the increasing use of stents during percutaneous transluminal coronary angioplasty, it is unclear whether systematic stenting is superior to a strategy of provisional stenting in which stents are placed only in patients with unsatisfactory results or as a bail-out procedure., Methods: Two hundred fifty-one patients undergoing elective coronary angioplasty were randomly assigned either to provisional stenting (group 1, in which stenting was performed if postangioplasty coronary velocity reserve was <2.2 and/or residual stenosis > or =35% or as bail-out) or to systematic stenting (group 2). The primary end point was the six-month angiographic minimal lumen diameter (MLD). Major adverse cardiac events were secondary end points (death, acute myocardial infarction and target lesion revascularization)., Results: Stenting was performed in 48.4% of patients in group 1 and 100% of patients in group 2 (p<0.01). Six months after angioplasty, the MLD did not differ between groups (1.90+/-0.79 mm vs. 1.99+/-0.70 mm, p = 0.39), as was the rate of binary restenosis (27.1% vs. 21.4%, p = 0.37). Among patients with restenosis, 13/32 (40.6%) in group 1 but 100% (25/25) in group 2 had in-stent restenosis (p<0.01). Target lesion revascularization (15.1% vs. 14.4% in groups 1 and 2 respectively, p = 0.89) and major adverse cardiac events (15.1% vs. 16.0%, p = 0.85) were not significantly different., Conclusions: Systematic stenting does not provide superior angiographic results at six months as compared with provisional stenting.

Objectives: We sought to identify the angiographic predictors of a future infarction, to study their interaction with time to infarction, patient risk factors and medications, and to evaluate their clinical utility for risk stratification., Background: Identification of coronary lesions at risk of acute occlusion remains challenging. Stenosis severity is poorly predictive but other stenosis descriptors might be better predictors., Methods: Eighty-four patients with an acute myocardial infarction and a coronary angiogram performed within the preceding 36 months (baseline angiogram), and after infarction were selected. All coronary stenoses (from 10% to 95% lumen diameter reduction) at baseline angiogram were analyzed by computer-assisted quantification. Each of the 84 lesions responsible for the infarction (culprit) was compared with the nonculprit stenoses (controls) in the same patient., Results: Culprit lesions were more symmetrical (symmetry index +15%; p < 0.001), had steeper outflow angles (maximal angle +4 degrees; p < 0.001), were more severe (percent stenosis +5%; p = 0.001) and longer (+ 1.5 mm, p = 0.01) than controls. The symmetry index and the outflow angles were the two independent predictors of infarction at three-year follow-up. Stenosis severity predicted only infarctions occurring within 1 year after angiography. In moderately severe stenoses (40% to 70% stenosis), stratification using the symmetry index and outflow angles accurately predicted lesions remaining free of occlusion and infarction at three-year follow-up., Conclusions: Better characterization of stenosis geometry might help to understand the pathophysiologic mechanisms triggering coronary occlusion and to stratify patients for improved care.

The radial artery is being used with increasing frequency to replace the saphenous vein as a coronary artery bypass graft, in the belief that it will provide improved long-term patency. Several centers have confirmed that the early results of surgery using the radial artery seem to be better than those obtained with saphenous grafts. Despite these apparent gains, early failure of the radial artery graft can occur and is frequently associated with symptomatic myocardial ischemia. Percutaneous angioplasty is an alternative to reoperation to treat lesions occurring on radial artery grafts. We report on 4 patients who underwent angioplasty of radial artery grafts.

Left ventricular (LV) systolic function is partly determined by severity of coronary artery disease and is improved by angiotensin-converting enzyme (ACE) inhibition, at least in post-infarct patients. Because the ACE insertion/deletion (I/D) gene polymorphism is associated with circulating and tissue ACE activity, we sought to evaluate the role of this genetic variant on LV function in patients studied with coronary angiography, taking into account coronary vessel anatomy and history of infarction. Coronary artery disease extent scores, coronary artery patency, and LV ejection fraction were assessed in 400 consecutive Caucasian patients referred for established or suspected ischemic heart disease. A previous infarction had occurred in 141 patients an average of 3.7 years before the study. The ACE DD genotype, compared with the ACE ID/II genotype, was associated with a 2.7% higher ejection fraction in noninfarct patients (p = 0.047) but a 5.0% lower ejection fraction in post-infarct patients (p = 0.047). An interaction effect between the ACE I/D gene polymorphism, the infarction status, and LV ejection fraction was observed in the whole population (p = 0.003), in patients with no disease and 1-, 2-, and 3-vessel diseases (p = 0.03 and p = 0.06, respectively), and in those with chronically occluded coronary vessels (p = 0.02). The influence of the ACE I/D gene polymorphism on LV function is modulated by infarction status and coronary anatomy.

Genetic polymorphisms of the renin-angiotensin system (RAS) have been associated with coronary artery disease (CAD) but no relation between these polymorphisms and coronary atherosclerosis has yet been systematically evaluated. The CORGENE study is a cross-sectional study involving 463 Caucasians who underwent standardized coronary angiography for established or suspected CAD [156 patients with a previous myocardial infarction (MI), 307 without MI]. Four angiographic scores assessing the extent and severity of the coronary lesions were obtained from a double visual analysis of each angiogram, arbitration being achieved by a quantitative measurement. Three different genotypes were analyzed: the angiotensin I-converting enzyme insertion/deletion (ACE I/D) polymorphism, the Met to Thr change at position 235 of the angiotensinogen gene (AGT M235T) and the A to C transition at position 1166 of the angiotensin II type-1 receptor gene (AT1R A1166C). No significant association was observed between these polymorphisms and the clinical characteristics of MI and non-MI subjects. While most classical risk factors were positively correlated with the angiographic scores, no significant relationship could be established with the three genotypes (r ranging from -0.08 to 0.05). Only one significant correlation was observed: between the presence of the AGT 235T allele and the extent of the coronary lesions (r = -0.19, P = 0.04) in patients with low-risk status. These overall results are not in favor of a role of these RAS genetic polymorphisms in the development of coronary atherosclerosis.