Search

Aims Compared with placebo, abciximab has been associated with mortality reduction at late follow-up. The TARGET trial was performed to test whether tirofiban and abciximab provide similar efficacy outcomes among patients undergoing non-emergent, stent-based percutaneous coronary intervention. We report here the 1-year mortality of the study population. Methods and results In 18 countries at 149 hospitals, 4809 patients undergoing elective or urgent stent implantation were randomly assigned a bolus and infusion of tirofiban or abciximab. Ischaemic events were assessed at 30 days and 6 months and mortality was assessed at 1 year. We previously reported that abciximab was superior to tirofiban considering the composite rate of death or myocardial infarction at 30 days among all patients and at 6 months among those with an acute coronary syndrome (ACS). At 1-year follow-up death occurred in 46 (1.9%) patients who received tirofiban and 42 (1.7%) patients who received abciximab (hazard ratio 1.10, 95% CI 0.72–1.67; P =0.660). Mortality rates for patients with ACS were 2.3% with tirofiban vs. 2.2% with abciximab (hazard ratio 1.03, 95% CI 0.64–1.67; P =0.897) and those without ACS were 1.4 vs. 1.0% (hazard ratio 1.32, 95% CI 0.56–3.13; P =0.530). Conclusion At 1 year, tirofiban provided a similar level of survival benefit compared with abciximab.

Implementing clinical practice guidelines improves outcomes. This has been shown by several large scale registries. However, in spite of this, guidelines are poorly implemented in clinical practice for a wide variety of reasons. We examine the reasons behind the low uptake of guidelines into routine medical practice. Many physicians are simply not aware that guidelines exist; or they do not believe in them; or they simply do not care to implement them. Economic and social factors may also influence uptake of guidelines. It is the role of professional societies to disseminate best scientific knowledge, and ensure optimum implementation of guidelines. This can be achieved through educational activities and CME credit. Close collaboration between the profession, health authorities, and maybe even the industry could improve uptake of clinical practice guidelines, and thereby improve patient outcome.

Background Factor Xa plays a central role in the generation of thrombin, making it a novel target for treatment of arterial thrombosis. Fondaparinux, a synthetic pentasaccharide, is a factor Xa inhibitor, which has been shown to be superior to enoxaparin for the prevention of venous thrombosis. We designed a large, phase III, randomized trial to evaluate the efficacy and safety of fondaparinux compared with enoxaparin in acute coronary syndromes. Study design The OASIS-5 trial is a randomized, double-blind trial of fondaparinux versus enoxaparin in 20,000 patients with unstable angina or non-ST-segment elevation myocardial infarction. The primary objective is to determine whether fondaparinux is noninferior to enoxaparin in preventing the composite of death, new myocardial infarction, and refractory ischemia at 9 days (primary outcome) and at 30 days (secondary outcome) after randomization. There will be additional follow-up of all patients for 3 to 6 months after randomization. If noninferiority is established at 9 days, superiority will be tested. The primary safety outcome is to evaluate the rates of major bleeds in the 2 groups with the balance of benefit and risk assessed by comparing the impact on the composite of the primary and safety outcomes. Secondary outcomes are each component of the composite primary outcome separately at days 9, 30, and up to 6 months. The TIMACS, a major substudy using a partial 2x2 factorial design evaluating whether early angiography and intervention (within 24 hours) are superior to a more delayed approach (after 36 hours) in reducing major ischemic events at 6 months after randomization. Conclusions The MICHELANGELO OASIS 5 program will provide a comprehensive and reliable evaluation of fondaparinux in a broad spectrum of patients with ACS.

International audience; BACKGROUND: Survival after acute myocardial infarction (MI) is linked to multiple factors, including mild or severe chronic kidney dysfunction. The aim of this study was to determine to what extent a reduction in glomerular filtration rate (GFR) influences 1-year mortality when risk level at admission and quality of care are taken into account. METHODS: A prospective registry was carried out in a geographically delimited area, including all patients admitted with a diagnosis of acute MI over a 6-month period. The GFR was calculated from serum creatinine levels, and patients were stratified into 3 groups: GFR1 >59 mL/min per 1.73 m2, GFR2 >29 and

Over the past twenty years, practice guidelines have become an increasingly popular tool for synthesis of clinical information. The objectives of guidelines are to enhance the appropriateness of practice, improve quality of cardiovascular care, lead to better patient outcomes, improve cost-effectiveness, help authorities to decide on the approval of drugs and devices and identify areas of research needed. Guidelines may also be used as quality measurement for the health insurance. Evidence-based medicine is a relatively recent concept: indeed, it is only within the past two decades that prospective, randomized clinical trials have become widely accepted, creating the foundation for modern clinical research. Thanks to the evidence coming from these trials, physicians have been forced to abandon some concepts that were previously considered ‘logical’ or ‘good common sense’ and which had provided the rationale for what was in fact empirical treatment. The scientific community has been adopting the new concepts introduced by ‘evidence based medicine’ so rapidly that we can hardly remember our recent past. For example, not so many years ago, cardiologists were taught, based on theoretical assumptions and some small acute studies, to avoid beta-blockers in patients with heart failure. Now, after several randomized trials have disputed that concept using a gradual step dosage, we learn that these are precisely the patients who may benefit most from that therapy.1,2Another example of the risk of linking the practice of medicine to what ‘seems logical’, comes from the assumption made in the seventies and in the eighties that reducing premature ventricular contractions would lower arrhythmic deaths. To our surprise, we learnt from the Cardiac Arrhythmias Suppression Trial (CAST), that drugs highly ‘effective’ in reducing premature ventricular beats actually increased patient mortality due to proarrhythmia .3There are of course many more examples of how carefully collected data may …

To assess the immediate and late clinical outcome of left anterior descending artery ostial lesions treated with percutaneous coronary intervention.Seventeen patients (6 females and 11 males) treated with percutaneous coronary intervention for ostial left anterior descending artery stenoses have had clinical follow-ups over 12 months. Clinical events were defined as an occurrence of death, myocardial infarction, recurrent angina, and requiring repeat revascularization (either by angioplasty or by surgery). A matched population treated with coronary bypass surgery was selected based on the similarities in age, left ventricular ejection fraction and the number of diseased vessels. Kaplan-Meier event-free survival curves were generated and the matched comparison was done using the Chi-square test (Mc Neimar method).In the catheter-based angioplasty group, the patients' mean age was 63 +/- 8 years. One patient was treated with directional atherectomy plus balloon, 6 with rotational atherectomy plus balloon, 7 with stent and 3 with rotational atherectomy plus stent. Glycoprotein IIb/IIIa antagonist was used in 4 cases. Initial procedural success without major complications was achieved in all cases. The mean reference diameter was 2.90 +/- 0.48 mm. The minimum lumen diameter increased from 1.05 +/- 0.30 mm to 2.40 +/- 0.45 mm, and the diameter stenosis decreased from 64% +/- 7% to 8% +/- 13%. During the follow-up period, adverse events requiring repeat revascularization occurred in 8 patients. The event-free probability was 0.42 +/- 0.14 in a two-year period. In a matched population treated with bypass surgery (single mammary graft), only one event occurred, and the difference in event-free survival in two-year period between the two patient groups was significant.Percutaneous coronary intervention for left coronary descending artery ostial lesion is technically feasible and safe, leading to an optimal early success rate, but has a higher risk of late restenosis and greater need for repeat revascularization than coronary bypass surgery.

The medical profession, in particular cardiologists, acknowledge the fact that during the last 30 years, much of the progress made in the field of medicine has resulted from fruitful and close collaboration between academia and the pharmaceutical industry. However, during the last decade, this relationship has changed considerably. The industry increasingly carries out its own research, development of drugs and trials, according to its own agenda. As a result, academia has lost its influence. This has led to a dramatic increase in the cost of clinical randomised trials. In the meantime, academic careers and research have become less attractive to physicians. Funding for research is increasingly devoted to basic science, in particular genomics, and little is left for clinical research. As a result, many important clinical trials in various areas of medicine, including cardiology, remain unfunded.

The classification of acute coronary syndromes takes into account new data concerning pathophysiology and management. Acute coronary syndromes have a common substrate, namely rupture or erosion of an atherosclerotic plaque leading to thrombus formation and distal embolization, which is responsible for microinfarction with release of myocardial proteins (enzymes and troponins). In the context of acute chest pain, two different presentations of acute coronary syndromes are distinguished on the basis of electrocardiographic findings, according to wether or not there exist persistent ST-segment elevation. Acute coronary syndromes with permanent ST-elevation generally lead to Q-wave infarction and require urgent reperfusion. Acute coronary syndromes without permanent ST-elevation can be further subdivided into: non-Q-wave infarction, when there is release of markers of myocardial cell death, with a prognosis warranting aggressive medical therapy, early coronary angiography and revascularization whenever possible; unstable angina, in the absence of release of markers of cell death, with a more favourable prognosis allowing ambulatory management.

Nadroparin, a low-molecular-weight heparin (LMWH), is an alternative to unfractionated heparin for the acute management of patients with non-ST elevation acute coronary syndrome (ACS): unstable angina or non-Q-wave myocardial infarction. However, unfractionated heparin can be substituted for LMWH in patients requiring percutaneous coronary interventions (PCIs) for the duration of the procedure. The tolerability of this anti-thrombotic regimen (i.e. unfractionated heparin for the duration of PCIs, preceded and followed by subcutaneous injection of nadroparin) is not yet documented.This open-label 6-day study was carried out in 302 patients to test the tolerability of this anti-thrombotic regimen in patients requiring PCIs. The primary end-point of the study was the incidence of major haemorrhage over the whole study duration (6 days). The secondary end-point was the need for transfusion and vascular repair after PCI.The incidence of major haemorrhage in patients undergoing coronary angiography (CA) without or with PCIs was 1.4% and 1.3%, respectively, and the incidence of minor haemorrhage was 10.7% and 23.5%, respectively. These results are consistent with published data.These results suggest that CA and PCIs can be performed safely in patients being treated for unstable angina or non-Q-wave myocardial infarction receiving nadroparin pre- and post-coronary procedure and/or intervention, substituted by unfractionated heparin for the duration of the intervention.

To evaluate in-hospital course and long-term outcome of acute massive pulmonary thromboembolism after thrombolysis and to determine its prognostic factors.A total of 260 patients was retrospectively reviewed and followed up for 3.9 - 8.4 years. Close attention was paid to the clinical events, including death, recurrent thromboembolic events, chronic thromboembolic pulmonary hypertension, bleeding complications attributed to anticoagulant therapy, and requirement of oxygen therapy at home. Kaplan-Meier event-free survival curves were generated.The in hospital mortality rate was 8.5%, in which 68.2% were due to pulmonary thromboembolism itself, and the follow-up mortality rate was 31.7%, in which 29.2% were due to recurrent embolism. Univariate analysis showed that six variables were associated with the occurrence of clinical events: (1) Prior thromboembolic diseases; (2) Duration of anticoagulant therapy less than 6 months; (3) Inferior vena cava filter placement; (4) Remaining right ventricular dysfunction/dilatation after thrombolysis detected by echocardiography; (5) Systolic pulmonary pressure50 mm Hg after thrombolysis by echocardiography; (6) Greater than 30% residual obstruction of pulmonary vasculature identified by lung ventilation/perfusion scintigraphy before hospital discharge. Multivariate analysis identified three independent risk factors for long-term mortality of acute massive pulmonary thromboembolism after thrombolysis: (1) Systolic pulmonary artery pressure50 mm Hg (RR: 3.78, 95% CI = 2.70 - 4.86); (2) Right ventricular dysfunction/dilatation (RR: 2.18, 95% CI = 1.48 - 2.88); (3) Greater than 30% obstruction of pulmonary vasculature (RR: 1.99, 95% CI = 1.25 - 2.70).Doppler echocardiographic assessment after thrombolysis and ventilation/perfusion scintigraphy prior to hospital discharge are valuable to establish a new baseline condition, which is informative for risk stratification and prognostication of long-term outcome.

The cutting balloon (CB) is a specialized device designed to create discrete longitudinal incisions in the atherosclerotic target coronary segment during balloon inflation. Such controlled dilatation theoretically reduces the force needed to dilate an obstructive lesion compared with standard percutaneous transluminal coronary angioplasty (PTCA). We report a multicenter, randomized trial comparing the incidence of restenosis after CB angioplasty versus conventional balloon angioplasty in 1,238 patients. Six hundred seventeen patients were randomized to CB treatment, and 621 to PTCA. The mean reference vessel diameter was 2.86 +/- 0.49 mm, mean lesion length 8.9 +/- 4.3 mm, and prevalence of diabetes mellitus in patients was 13%. The primary end point, the 6-month binary angiographic restenosis rate, was 31.4% for CB and 30.4% for PTCA (p = 0.75). Acute procedural success, defined as the attainment of

Summary Background Two placebo-controlled trials testing intravenous platelet glycoprotein IIb/IIIa antagonists in the setting of percutaneous coronary revascularisation with intracoronary stents have shown a durable reduction in ischaemic events to 6 months. These trials differed regarding their patient population, IIb/IIIa inhibitor, and reported extent of benefit. Whether a small-molecule agent affecting only the IIb/IIIa receptor would provide a similar outcome for ischaemic events and clinical restenosis at 6 months when directly compared with a monoclonal antibody known to affect several integrin receptors is unknown. Methods In 18 countries at 149 hospitals, 4809 patients undergoing elective or urgent stent implantation were randomly assigned a bolus and infusion of tirofiban or abciximab. Patients were followed for 6 months for the occurrence of death, myocardial infarction, and any targetvessel revascularisation. The results at 30 days have been reported previously. Findings At 6 months the composite endpoint of death, myocardial infarction, and target-vessel revascularisation occurred in 356 (14·8%) patients who received tirofiban and 345 (14·3%) patients who received abciximab (hazard ratio 1·04, 95% CI 0·90–1·21, p=0·591). The rates for the individual endpoints were 191 (8·0%) versus 159 (6·6%) for myocardial infarction (hazard ratio 1·21, 95% CI 0·98–1·50; p=0·074), 26 (1·1%) versus 25 (1·0%) for death (1·04, 0·60–1·80; p=0·893), and 194 (8·1%) versus 208 (8·6%) for target-vessel revascularisation (0·93, 0·77–1·14; p=0·495). Interpretation At 6 months, tirofiban provided a similar level of overall protection to abciximab against the composite of death, myocardial infarction, and any targetvessel revascularisation.

Aortic dissection (AD) is a disease with a high-risk of mortality. Late deaths are often related to complications in nonoperated aortic segments. Between 1984 and 1996, we retrospectively analyzed the data of 109 patients with acute AD (81 men and 28 women; average age 61 ± 14 years). All imaging examinations were reviewed, and a magnetic resonance imaging examination was performed at the time of the study. Aortic diameters were measured on each aortic segment. Predictive factors of mortality were determined by Cox’s proportional hazard model, in univariate and multivariate analyses, using BMDP statistical software. Follow-up was an average of 44 ± 46 months (range 24 to 164). Actuarial survival rates were 52%, 46%, and 37% at 1, 5, and 10 years, respectively, for type A AD versus 76%, 72%, and 46% for type B AD. Predictors of late mortality were age >70 years and postoperative false lumen patency of the thoracic descending aorta (RR 3.4, 95% confidence intervals 1.20 to 9.8). Descending aorta diameter was larger when false lumen was patent (31 vs 44 mm; p = 0.02) in type A AD. Furthermore, patency was less frequent in operated type A AD when surgery had been extended to the aortic arch. Thus, patency of descending aorta false lumen is responsible for progressive aortic dilation. In type A AD, open distal repair makes it possible to check the aortic arch and replace it when necessary, decreases the false lumen patency rate, and improves late survival.

Objective To assess the agreement between left ventricular (LV) volumes and ejection fraction (EF) determined by two-dimensional echocardiography (2-D echo) and by cineangiography in postinfarction patients. Design LV end-diastolic and end-systolic volumes indexed (EDVI and ESVI) to body surface area as well as EF were determined by both methods in all patients. Setting Multicenter trial conducted in five university hospitals. Patients 63 patients, 61 male, two female, mean age 55.5 +/- 10.4 years, suffering from a recent myocardial infarction. Eighty-one pairs of measurements were available. Methods The results of biplane 2-D echo measures, using apical four-chamber (4C) and two-chamber (2C) views were compared to those of a 30 degrees right anterior oblique cineangiography projection, using either the apical method of discs or the area-length 2-D echo method. Moreover, eyeball EF was estimated at 2-D echo and cineangiography, and was compared to the conventional methods. The agreement between results was assessed by the Bland and Altman method. Results The agreement between 2-D echo and cineangiography results was poor. Mean differences (MD) were -21.8 (EDVI, ml/m(2)), -9.5 (ESVI, ml/m(2)), and -0.9 (EF, %), respectively for 2-D echo method of discs versus cineangiography, and -23.2, -9.3, and -5.7 for area-length 2-D echo versus cineangiography. For EF (%), MD was -3.6 for eyeball cineangiography versus cineangiography, -1.3 for eyeball 2-D echo versus method of discs, and +0.30 for eyeball 2-D echo versus area-length 2-D echo, respectively. Two-dimensional echo is likely to underestimate LV volumes compared to cineangiography, especially for largest volumes. Even for EF, discrepancies are large, with a lack of agreement of 21%-25% between conventional methods, but agreement is better between eyeball EF and usual methods. Conclusions Even with modern echocardiographic devices, agreement between 2-D echo and cineangiography-derived LV volumes and EF remains moderate, and both methods must not be considered interchangeable in clinical practice.

Rationale Rotational atherectomy makes possible to attempt small and calcified arteries while Drug Eluting Stents (DES) properties may reduce the restenosis process, rendering this combination attractive in selected cases. We compared 1year clinical outcome after rotational atherectomy following by either DES or Bare Metal Stents (BMS) implantation. Methods Single centre registry including all consecutive cases of rotational atherectomy use. Clinical follow-up was obtained in all patients. Propensity score for being treated with a DES was calculated using 18 clinical, angiographic and procedural variables. Comparison was adjusted on 4 strata of the propensity score. Results Between 2002 and 2008, 223 patients were treated: 114 with BMS and 110 with DES. Most of the patients with BMS between 2002 and 2004 and later with DES. No significant difference was observed in clinical characteristics between groups: age 70 years, reference diameter 2.40±0.60mm, lesion length 10±9mm. Two cases of coronary perforation occurred, 7 lesion failure, and 12 transcient no-reflow. The use of GP2b3a inhibitors was similar in both groups, but, compared with BMS, patients in the DES group had longer duration of combination of aspirin and Clopidogrel. At one year, significantly lower rates of vessel revascularisation (2% vs 12%, p=0.005), of all cause mortality (5% vs 14%, p=0.05) and of MACE (10% vs 22%, p=0.02) were observed in the DES than in the BMS group. Adjustment on the strata of the propensity score did not change significantly these results (figure). Conclusions Despite propensity score adjusted, this comparison has limitations. After rotational atherectomy we observed clear benefit for DES implantation over BMS on vessel revascularisation, mortality and MACE rates. Download : Download full-size image

Percutaneous intervention for the first episode of in-stent restenosis was performed in 177 patients 5.4 +/- 0.3 months after native coronary stent implantation. Medical records were reviewed and patients contacted 13.3 +/- 1.2 months after in-stent intervention to ascertain the subsequent clinical course. The effects of demographic, procedural, and angiographic variables on clinical outcomes were determined. At 2 years, Kaplan-Meier estimated survival was 93 +/- 3% and freedom from death, myocardial infarction, and a third target artery revascularization (TAR) was 67 +/- 4%. The actuarial frequency of a third TAR was 26 +/- 4% at 1 year. Stratification of outcomes according to timing of in-stent intervention revealed an approximate twofold higher frequency of adverse events among patients with early (/=3 months) in-stent restenosis. Advanced age (p = 0.019), prior coronary bypass (p = 0. 017), and early in-stent intervention (p = 0.006) independently predicted increased mortality at follow-up. Systemic hypertension (p = 0.004), diabetes mellitus (p = 0.044), and early in-stent intervention (p0.0001) independently predicted a third TAR. These variables (p = 0.007, p = 0.027, and p0.0001, respectively) also independently predicted a composite end point consisting of death, myocardial infarction, and a third TAR. No angiographic variable predicted outcome after in-stent intervention. Thus, long-term outcome following in-stent intervention was favorable. Early in-stent intervention, advanced age, hypertension, and diabetes predicted adverse outcomes.

Repeat balloon angioplasty is a widely used therapeutic option for in-stent restenosis, but the optimal balloon inflation pressure has not yet been determined. We used angiography and intravascular ultrasound imaging to assess the mechanism and results of lumen enlargement at various inflation pressures. Thirteen consecutive patients with restenosis post-Palmaz-Schatz stent implantation were submitted to a four-step balloon angioplasty using increasing balloon pressure of 2, 4, 8, and12 atm. As a global result, the lumen size was only 80% of that observed at stent implantation. Significant changes in angiographic minimal lumen diameter, minimal lumen cross-sectional area, and lumen volume were observed after each step except after the highest-pressure inflation. At low inflation pressure (8 atm), the decrease in neointimal tissue and the stent over expansion explained the lumen enlargement, whereas after further high inflation pressure (8 atm), only additional stent over expansion was observed. These results suggest that only moderate balloon inflation pressure (up to 12 atm) is needed for angioplasty of post-Palmaz-Schatz stent restenotic lesions.

Summary Aim of the study. To assess the antithrombotic properties of SR90107/ORG31540, a sulfated pentasaccharide, which enhances specifically antithrombin III mediated inactivation of factor-Xa, in a clinical setting known to promote arterial thrombosis, i.e. coronary angioplasty. Methods and results. Percutaneous transluminal coronary angioplasty (PTCA) was carried out with conventional balloons with a single 5 min intravenous infusion of 12 mg pentasaccharide, and 500 mg intravenous aspirin. Heparin was not allowed before, during PTCA, and within 24 h after PTCA. The primary end point was the rate of abrupt vessel closure during and within 24 h after the procedure. The sample size was set at 60 evaluable patients, in order to be able to conclude with a good level of confidence (>95%) that the abrupt vessel closure rate was less than 10%, if less than 3 abrupt vessel closures were observed. Seventy-one patients were included in the study, of whom 10 needed elective stenting, and were not considered as evaluable for efficacy. Two out of the 61 remaining evaluable patients experienced acute vessel closure during the study period [3.28%, 95% confidence interval (0.4%; 11.4%)]. No major bleeding occurred. The drug plasma concentrations reached 1.91 ± 0.39 mg/l, 10 min after pentasaccharide injection, and decreased on average to 1.18 ± 0.27 mg/l at 2 h, and to 0.36 ± 0.11 mg/l at 23 h after administration of pentasaccharide. Activated clotting time (ACT) and activated partial thromboplastin (aPTT) time remained within normal range. Thrombinantithrombin complex levels fell from 22 ± 17.1 to 4.5 ± 3.4 μg/ml, prothrombin fragment 1+2 levels decreased from 2.15 ± 1.01 to 1.73 ± 0.87, and activated factor VII levels decreased from 43.4 ± 16.8 mU/ml to 18.9 ± 7.3 mU/ml respectively from baseline to 2 h following injection of the tested drug. Conclusions. Administration of pentasaccharide led to the inhibition of thrombin generation without modification of aPTT and ACT. The rate of abrupt vessel closure was within range of rates reported in historical series. Thus we conclude that the anti-thrombotic activity of pentasaccharide, as shown in this pilot trial in the setting of coronary angioplasty, deserves further investigation.

Objective—To assess the long term functional result after percutaneous mitral commissurotomy and identify the predictors of event-free survival following 10 years of experience. Design—Analysis of clinical, echocardiographic, and haemodynamic variables at baseline and after the procedure by univariate and multivariate analyses (Cox model). Setting—University hospital. Patients—532 consecutive patients receiving percutaneous mitral commissurotomy in the same institution. Results—The mean (SD) follow up was 3.8 (4.0) years. Survival at 3, 5, and 7.5 years was 94%, 91%, and 83%, respectively; event-free survival was 84%, 74%, and 52%. Mitral valve anatomy was identified as the strongest independent predictor of event-free survival. Age, cardiothoracic ratio, mean pulmonary artery pressure, and mean echocardiographic mitral gradient after commissurotomy were also found to be independent predictors of long term functional result. Event-free survival was 92%, 84%, and 70% at 3, 5, and 7.5 years in patients with favourable anatomy (echo score = 1), 86%, 73%, and 34% in patients with intermediate anatomy (echo score = 2), and 45%, 25%, and 16% in patients with unfavourable anatomy (echo score = 3). In patients aged ⩽ 65 years, the event-free survival rate was 80%, 70%, and 45% at 3, 5, and 7.5 years v 52%, 38%, and 17% in patients aged > 65 years. Conclusions—The anatomical form of the mitral valve and the patient's age were the most powerful predictors of event-free survival. Patients with intermediate or unfavourable anatomy and those aged > 65 years have low 5 and 7.5 year event-free survival rates. This must be taken into account when discussing the indications for percutaneous mitral commissurotomy; immediate mitral valve replacement is a reasonable alternative to balloon mitral commissurotomy in patients with higher risk of functional deterioration after the procedure. Keywords: valvoplasty; mitral valve stenosis

Over the last two decades, major improvements in clinical outcome have been achieved in the management of acute coronary syndromes (ACS), with or without ST-segment elevation. In both these clinical settings, the pharmacological approach comprising anti-platelet agents, (or a combination thereof), anticoagulants, thrombolytic treatment in case of ST-elevation MI (STEMI) combined with mechanical or surgical revascularization or reperfusion, has led to a dramatic reduction in the rate of ischaemic events, namely death, death/myocardial infarction (MI), or death/MI/stroke. However, this has been achieved at the cost of a higher risk of bleeding complications, which were considered, until recently, to be inherent to ACS management, and to be a side effect devoid of serious clinical implications, except for intra-cranial bleeding. Bleeding complications were thought to be the price to pay for the improvement in the risk of ischaemic events, and were considered to be easily controlled, particularly thanks to a liberal transfusion policy. In this context, the risk factors for bleeding have been identified, and include baseline characteristics, such as age, female gender, renal failure, diabetes, and heart failure. In addition, the number and dosage of anti-thrombotic drugs, the use of fibrinolytic treatments, and the use of invasive strategies, required to achieve mechanical reperfusion or revascularization, also play an important role.1,2 However, over the last 5 years, it has become clear that bleeding complications occurring during the initial phase of ACS have a considerable impact on prognosis, especially in terms of death, MI, and stroke, both in the short- and long-term. A four- to five-fold increase in the risk of death, MI, and stroke at 30 days has been observed in patients with bleeding events, as compared to those without.2–4 The potential mechanisms by which … Corresponding author. Tel: +33 381 668 539; fax: +33 381 668 582. E-mail address : jpbassan{at}univ-fcomte.fr

OBJECTIVE: To assess the reliability of aortic valve area planimetry by multiplane transoesophageal echocardiography (TOE) in aortic stenosis. DESIGN: Study of the diagnostic value of aortic valve area planimetry using multiplane TOE, compared with catheterisation and the continuity equation, both being considered as criterion standards. SETTING: University hospital. PATIENTS: 49 consecutive patients (29 male, 20 female, aged 44 to 82 years, average 66.6 (SD 8.5)), referred for haemodynamic evaluation of an aortic stenosis, were enrolled in a prospective study. From this sample, 37 patients were eligible for the final analysis. METHODS: Transthoracic and multiplane transoesophageal echocardiograms were performed within 24 hours before catheterisation. At transthoracic echo, aortic valve area was calculated by the continuity equation. At TOE, the image of the aortic valve opening was obtained with a 30-65 degrees rotation of the transducer. Numerical dynamic images were stored on optical discs for off-line analysis and were reviewed by two blinded observers. Catheterisation was performed in all cases and aortic valve area was calculated by the Gorlin formula. RESULTS: Feasibility of the method was 92% (48/52). The agreement between aortic valve area measured at TOE (mean 0.88 (SD 0.35) cm2) and at catheterisation (0.79 (0.24) cm2) was very poor. The same discrepancies were found between TOE and the continuity equation (0.72 (0.26) cm2). TOE planimetry overestimated aortic valve area determined by the two other methods. Predictive positive and negative values of planimetry to detect aortic valve area < 0.75 cm2 were 62% (10/16) and 43% (9/21) respectively. CONCLUSIONS: Planimetry of aortic valve area by TOE is difficult and less accurate than the continuity equation for assessing the severity of aortic stenosis.

SD, standard deviation; VKA, vitamin K antagonist. aFirst-degree relative with premature cardiac history (age

Autores/Miembros del Grupo de Trabajo Presidentes: Kristian Thygesen (Dinamarca), Joseph S. Alpert (Estados Unidos), Harvey D. White (Nueva Zelanda); Subcomite sobre Biomarcadores: Allan S. Jaffe (Estados Unidos), Hugo A. Katus (Alemania), Fred S. Apple (Estados Unidos), Bertil Lindahl (Suecia) y David A. Morrow (Estados Unidos); Subcomite del ECG: Bernard R. Chaitman (Estados Unidos), Peter M. Clemmensen (Dinamarca), Per Johanson (Suecia) y Hanoch Hod (Israel); Subcomite de Imagen: Richard Underwood (Reino Unido), Jeroen J. Bax (Paises Bajos), Robert O. Bonow (Estados Unidos), Fausto Pinto (Portugal) y Raymond J. Gibbons (Estados Unidos); Subcomite de Clasificacion: Keith A. Fox (Reino Unido), Dan Atar (Noruega), L. Kristin Newby (Estados Unidos), Marcello Galvani (Italia) y Christian W. Hamm (Alemania); Subcomite de Intervencion: Barry F. Uretsky (Estados Unidos), P. Gabriel Steg (Francia), William Wijns (Belgica), Jean-Pierre Bassand (Francia), Phillippe Menasche (Francia) y Jan Ravkilde (Dinamarca); Subcomite de Ensayos y Registros: E. Magnus Ohman (Estados Unidos), Elliott M. Antman (Estados Unidos), Lars C. Wallentin (Suecia), Paul W. Armstrong (Canada) y Maarten L. Simoons (Paises Bajos); Subcomite de Insuficiencia Cardiaca: James L. Januzzi (Estados Unidos), Markku S. Nieminen (Finlandia), Mihai Gheorghiade (Estados Unidos) y Gerasimos Filippatos (Grecia); Subcomite de Epidemiologia: Russell V. Luepker (Estados Unidos), Stephen P. Fortmann (Estados Unidos), Wayne D. Rosamond (Estados Unidos), Dan Levy (Estados Unidos) y David Wood (Reino Unido); Subcomite de Perspectivas Globales: Sidney C. Smith (Estados Unidos), Dayi Hu (China), Jose Luis Lopez-Sendon (Espana), Rose Marie Robertson (Estados Unidos), Douglas Weaver (Estados Unidos), Michal Tendera (Polonia), Alfred A. Bove (Estados Unidos), Alexander N. Parkhomenko (Ucrania), Elena J. Vasilieva (Rusia) y Shanti Mendis (Suiza)

Resume Une necessite evidente Il est indispensable d’ameliorer la prise en charge des patients hypercholesteromeliques car, selon l’etude Euroaspire II, a peine la moitie des patients coronariens hypercholesterolemiques traites ont des taux de lipides correctement controles. Un nouveau calcul du risque cardio-vasculaire Le risque cardio-vasculaire est desormais exprime seulement en risque de deces a 10 ans et non plus en risque de mortalite et evenements cardio-vasculaires. Un risque de deces superieur a 5 % definit une population a haut risque pour laquelle il convient d’etre plus exigeant avec des valeurs cibles de pression arterielle ou de cholesterol plus strictes. Les inhibiteurs de l’absorption intestinale du cholesterol L’ezetimibe bloque specifiquement l’absorption du cholesterol par les cellules intestinales. Il s’agit d’un mode d’action complementaire par rapport a celui des statines. Sa co-administration avec une statine obtient une reduction supplementaire du LDL cholesterol par rapport a celle obtenue avec la statine seule.

Important changes to the statutes of the European Society of Cardiology (ESC) were introduced on the occasion of the annual ESC congress in Vienna in September 2003. The Extraordinary General Assembly held at the annual congress approved massively the most important changes ever proposed to the constitution of the ESC over the last 20 years. These changes were necessary in order to offer the possibility of better and more far-reaching development in the different areas of expertise of our discipline. The changes paved the way for the official creation of two new Associations, one in the field of echocardiography, and the other in electrophysiology, created from the merged Working Groups on Arrhythmias and Cardiac Pacing. Associations are registered branches of the European Society of Cardiology. They can be derived from Working Groups or from professional or sub-specialty organisations existing outside of the ESC. The aim …

Mean pulmonary artery pressure (MPA), cardiac output (CO), and right ventricular ejection fraction (RVEF) were serially assessed with use of a 5-way, rapid response rate, Swan-Ganz catheter in 45 Pts submitted to thrombolytic therapy (TI) for massive pulmonary embolism (PE) defined as Miller score l 17/34, and mean pulmonary artery pressure g20 mmHg. Total pulmonary resistance (TPR) was determined from MPA and CO and expressed in dynes/sec/cm-5. Pulmonary angiography was performed before and 24 after TT. Streptokinase (STK) was used in 22 Pts, and tissue plasminogen activator (t-PA) in 23. T 0 T 1 h T2 h T 12 h TPR-STK 701 ± 261 591 ± 203 583 ± 211 380 ± 155 TPR-t-PA 735 ± 390 508 ± 330 405 ± 210 * 338 ± 142 RVEF-STK 0.18 ± 0.02 0.20 ± 0.07 020 ± 0.09 026 ± 0.10 RVEF-t-PA 0.18 ± 0.08 024 ± 0.09 0.27 ± 0.09 * 029 ± 0.09 * p l 0.05 between STK and t-PA A significant decrease in TPR inversely correlated to a significant increase in RVEF occurred in both treatment groups, but significantly more rapidly in the t-PA group than in the STK group. The difference was significant 2 hand 4 h after onset of TT, but had vanished at 12 h. Miller score, similar in both groups before TT, was identical in both groups at 24 h. Conclusion t-PA induced a significantly faster hemodynamic improvement than STK in massive PE, but with a catch-up phenomenon apparent 12 h after onset of therapy.

The Vienna congress of the European Society of Cardiology (ESC) was a resounding success, with even more active participants than in Berlin in 2002. This increasing attractiveness of the congress of the ESC is due to a range of factors including the venue of the congress, the quality of the programme, and its special ‘European’ flavour. The annual congress was, therefore, the best forum to announce a series of major initiatives that are in the pipeline in health and cardiovascular research. These projects will be driven by the ESC in partnership with the European Commission in one project, and the Irish Department of Health and Children for the other two projects, during the Irish Presidency of the European Union from January to June 2004. Despite the remarkable progress, unprecedented in human history, that has led to dramatic changes in the management and prognosis of diseases, particularly in cardiology, cardiovascular disease remains nonetheless the leading cause of permanent disability and mortality in developed countries, and will become the leading cause worldwide by the year 2020. By that time, it is expected that coronary artery disease will be the number one cause of disability on the planet. Nowadays, we are confronted today with new health challenges. Diabetes and obesity have become major health concerns. Smoking remains extremely popular, particularly amongst youngsters and females. Promotion of a healthy lifestyle and diet are scarce in Europe. Lastly, the ageing of the population and deteriorating economic status in some European countries also contribute to aggravating this situation, and help cardiovascular disease flourish. New solutions have to be envisaged to tackle these new challenges. Increased efforts in research and in the translation of this research into medical practice will be …

Two hundred and seventy patients, under 71 years of age and suffering from a less than 4 h infarction diagnosed according to clinical and electrocardiographic criteria, were included: two 90-patient groups were randomized and then treated with either anistreplase (30 mg iv over 5 min) or alteplase (10 mg bolus injection + 5000 IU heparin bolus injection, followed by 90 mg alteplase over 3 h), and compared with a consecutive control series of 90 patients treated with streptokinase (1.5 million U over 1 h). Intravenous heparin and aspirin (250 mg day-1) were then prescribed routinely. The three groups were comparable as regards age (55.2 +/- 10 years), male/female ratio (10.4), the site of the infarction (42% anterior, 55% inferior) and initial clinical seriousness (Killip I = 90%, II = 8%, III = 2%). The patients were thrombolysed in 17 community hospitals, and then referred to a university hospital with catheterization facilities. An efficacy score was determined, based on four parameters: two obtained from coronary angiography and left ventriculography performed on day 6 +/- 2 (N = 252) (asynergic score and patency of the infarct-related artery), one from Tl-tomography performed at rest (infarct size) and one from radionuclide angiography (global left ventricular ejection fraction) performed between day 15 and day 21 (N = 242). The score (range: 0-24 per patient) was 17.8 +/- 6.4 for alteplase, 17.7 +/- 6.0 for anistreplase and 18.1 +/- 6.0 for streptokinase respectively (NS).(ABSTRACT TRUNCATED AT 250 WORDS)

Background Antiplatelet therapy with clopidogrel and acetylsalicylic acid (ASA) reduces major cardiovascular events in patients with ST and non–ST-segment-elevation acute coronary syndromes (ACS). Recent mechanistic and clinical data suggest that higher loading and maintenance doses of clopidogrel may achieve a more rapid and greater degree of platelet inhibition that translates into improved clinical outcomes, but this is yet to be formally evaluated in an adequately powered randomized trial. Objectives To evaluate the efficacy and safety of (1) a higher loading and initial maintenance dose of clopidogrel compared with the standard-dose regimen and (2) high-dose ASA compared with low-dose ASA in patients with ST or non–ST-segment-elevation ACS managed with an early invasive strategy. Design Multicenter, international, randomized, 2×2 factorial design trial evaluating a clopidogrel high-dose regimen (600 mg loading dose on day 1 followed by 150 mg once daily on days 2 to 7, followed by 75 mg once daily on days 8-30) compared with the standard-dose regimen (300 mg loading dose on day 1, followed by 75 mg once daily on days 2-30) and high-dose ASA (300-325 mg daily) versus low-dose ASA (75-100 mg daily) in patients with ST or non–ST-segment-elevation ACS managed with an early invasive strategy. The clopidogrel dose comparison is double-blind and the ASA dose comparison is open-label. The primary outcome is the composite of death from cardiovascular causes, myocardial (re)infarction or stroke up to day 30. The primary safety outcome is major bleeding. The sample size is 18,000 to 20,000 patients. Conclusions The CURRENT-OASIS 7 trial will help to define optimal dosing regimens for clopidogrel and ASA in patients with ST and non–ST-segment-elevation ACS treated with an early invasive strategy.

El contenido de estas Guias de Practica Clinica de la Sociedad Europea de Cardiologia (ESC) ha sido publicado para uso exclusivamente personal y educativo. No esta autorizado su uso comercial. No s ...

Important changes to the statutes of the European Society of Cardiology (ESC) were introduced on the occasion of the annual ESC congress in Vienna in September 2003. The Extraordinary General Assembly held at the annual congress approved massively the most important changes ever proposed to the constitution of the ESC over the last 20 years. These changes were necessary in order to offer the possibility of better and more far-reaching development in the different areas of expertise of our discipline. The changes paved the way for the official creation of two new Associations, one in the field of echocardiography, and the other in electrophysiology, created from the merged Working Groups on Arrhythmias and Cardiac Pacing. Associations are registered branches of the European Society of Cardiology. They can be derived from Working Groups or from professional or sub-specialty organisations existing outside of the ESC. The aim …