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Left bundle branch block (LBBB) during exercise can be associated with chest pain. Though this association is mostly correlated with an underlying coronary artery disease, painful LBBB has been described in patients with normal coronary arteries. We report a case of exercise-induced LBBB with typical angina pectoris related to antimalarial prophylaxis with chloroquine in a 66-year old woman with normal coronary arteries, which was reversed after treatment discontinuation. The effect of chloroquine on the electrophysiological properties of nodal cardiac tissue is responsible for this rate-dependent LBBB. Precautions for future antimalarial prophylaxis are also discussed.

Resume Objectif Demontrer la faisabilite de l’angioplastie coronaire chez les patients tres âges. Prerequis Les patients tres âges sont de plus en plus frequents. La prevalence de la maladie coronaire etant importante dans ce groupe, ils sont donc susceptibles de beneficier d’une revascularisation coronaire. Methode Il s’agit d’une etude retrospective a partir de la base de donnees d’angioplastie coronaire de l’HIA Val de Grâce de janvier 2008 a mars 2009, comparant les caracteristiques des populations, la presentation clinique, le type de lesions, les procedures techniques, les resultats immediats et la survenue de complications per procedure ou au cours de l’hospitalisation, des patients âges de 85 ans ou plus par rapport a une population plus jeune. Resultats Au cours de cette periode, 3130 patients ont beneficie d’une angioplastie coronaire, parmi lesquels 85 patients âges d’au moins 85 ans. Les femmes etaient davantage representees dans ce groupe (24,7 vs 14,3 %, p = 0,007), mais il n’y avait pas de difference sur le risque cardiovasculaire. Les patients tres âges etaient d’avantage symptomatiques (syndrome coronarien aigu 59,52 vs 44 %, p = 0,004 ; ischemie silencieuse : 3,6 vs 25,7 %, p = 0,000003). La fraction d’ejection etait plus basse (FE p = 0,0001). Les lesions etaient plus complexes (B2 et C : 67,2 vs 57,1 % p = 0,027) et concernaient plus frequemment l’interventriculaire anterieure (85,9 vs 57,1 %, p = 0,000001).La reussite technique etait semblable dans les deux groupes (93,28 vs 94,32 %, p = 0,34) avec un taux similaire de complications per procedure (2,35 vs 1,5 %, p = 0,37). Cependant la mortalite hospitaliere chez les patients tres âges est apparue plus importante que chez les patients plus jeunes (7 vs 1,38 %, p = 0,0014). Conclusion L’angioplastie coronaire chez les sujets de 85 ans et plus est donc techniquement realisable avec un taux de succes satisfaisant et une morbi-mortalite hospitaliere acceptable compte tenu des comorbidites associees et de la severite de la maladie coronaire. De nouvelles etudes seraient donc necessaires afin d’editer des recommandations specifiques.

Summary Purpose Evaluate heart failure management in a Military Hospital in 2005. Methods Retrospective audit of 46 case records of patients hospitalised with heart failure within the framework of an accreditation procedure. Results The left ventricular ejection fraction was evaluated in 85% of cases during the reference hospital stay. Systolic heart failure was detected in 63% of cases. At least one NT-proBNP assay was performed for each patient. A global assessment was systematically performed, except for the mini mental state examination in patients aged over 75 years who represented 80% of patients. Initial therapeutic education was provided for 50% of systolic heart failure patients. Prescription rates in systolic heart failure were 76% for angiotensin-converting enzyme inhibitors, 7% for angiotensin receptor antagonists; 84% for at least one medicinal product in the above 2 classes; 68 % for beta-blockers and 32% for spironolactone. A hospital discharge report was available for 93% of the patients. Elective re-admissions to hospital for uptitration of treatment concerned 10% of systolic heart failure patients. Emergency hospital re-admissions after a cardiovascular event (usually decompensation), concerned 35% of patients, after an average duration of one year of follow-up. These latter re-admissions, often repeated, led to 4% of additional hospital deaths. The initial hospital mortality rate was 13%. Conclusion Therapeutic patient education is under development. Medication may still be optimised, both qualitatively and quantitatively. Surveillance is planned with a yearly audit.

La tromboangitis de Buerger es una enfermedad inflamatoria oclusiva no ateromatosa que afecta a las arterias de pequeno y mediano calibre y a las venas de la punta de los miembros, sobre todo de los dedos de pies y manos. Desde hace tiempo es conocida la estrecha relacion que existe entre la enfermedad y el tabaquismo, pero la etiopatogenia sigue siendo oscura: genetica, autoinmunitaria, toxica. La tromboangitis aparece fundamentalmente en pacientes de menos de 40 anos de edad, y el signo de alarma mas frecuente es la claudicacion plantar. Su evolucion es en episodios, acompanados por alteraciones vasomotoras, flebitis superficiales migratorias, alteraciones troficas como ulceraciones, incluso gangrena distal; las afectaciones viscerales son excepcionales. La arteriografia muestra oclusiones segmentarias distales, una circulacion colateral en forma de fina red helicoidal muy desarrollada. Las perspectivas terapeuticas incluyen una desintoxicacion absoluta y definitiva del tabaco, y una potencializacion de los resultados de las perfusiones de prostanoides o inmunosupresores en casos de alteraciones troficas. La prevencion de las heridas se basa en una educacion reforzada del paciente; la actuacion del podologo optimiza la atencion precoz de las ulceraciones y las alteraciones troficas. Las indicaciones quirurgicas son individualizadas y no deben realizarse con precipitacion: ha fracasado la simpatectomia, la estimulacion electrica medular mantiene unas indicaciones limitadas, las revascularizaciones ofrecen resultados limitados a causa de la mala calidad del procedimiento, las amputaciones quedan reservadas para los casos de gangrena y, a veces, se evitan gracias a las tecnicas de epiploplastia.

To determine the feasibility of percutaneous coronary intervention (PCI) in very old patients.The elderly are a growing population with a high prevalence of ischemic heart disease and then subsequent possibility to benefit from coronary interventions.We have conducted a retrospective study using our PCI database since January 2000. Population characteristics, clinical presentation, type of lesions, technical procedure, immediate results and in hospital outcome are compare between patients older than 85 and the other.Between January 2008 and March 2009, 3130 patients benefit from coronary angioplasty. Among them, 85 patients were older than 85. There were more female in this group (24.7 vs. 14.3%, P=0.007), but no difference in cardiovascular risk profile. The older was more symptomatic (acute coronary syndrome: 59.52 vs. 44%, P=0.004; silent ischemia: 3.6 vs. 25.7%, P=0.000003). The ejection fraction was worse (EF55%: 29.4 vs. 14.5%, P=0.0001). The lesion was more complex (B2 and C: 67.2 vs. 57.1% P=0.027) and concern more often the left descending artery (85.9 vs. 57.1%, P=0.000001). The technical success was similar in the two groups (93.28 vs. 94.32%, P=0.34) with similar rate of per procedure complications (2.35 vs. 1.5%, P=0.37). Nevertheless, the in-hospital rate mortality was higher in the older patients (7 vs 1.38%, P=0.0014).PCI is safe and safety in very old patients despite significant but acceptable increasing in-hospital mortality due to more severe disease and co morbidities. Further evaluations are necessary in order to edict specific recommendations.