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De nombreuses personnes victimes d’infarctus du myocarde (IDM) ne font pas appel aux secours médicalisés ou diffèrent l’appel en se mettant en danger. Plusieurs études se sont intéressées à ces comportements inadaptés en termes de survie. Toutefois leurs méthodes et leurs résultats apparaissent insuffisants pour comprendre ce qui se joue chez des sujets subissant une telle urgence de santé. Dans une épistémologie de la subjectivité, et en mobilisant le point de vue en première personne des malades, nous avons conduit une recherche qualitative pour explorer et comprendre : 1) le vécu du sujet pendant la crise cardiaque, dans son corps et dans son environnement, 2) les choix que les victimes d’infarctus opèrent pendant la crise, 3) les phénomènes mentaux influençant la décision de recourir aux soins, et en particulier, d’appeler les secours. Nous décrivons les tensions identitaires des sujets en crise et leurs effets sur leurs comportements pendant l’IDM. Notre recherche poursuit un objectif d’amélioration de la conception de l’éducation thérapeutique ciblant les phénomènes subjectifs qui déterminent les choix des malades au moment d’une urgence de santé. Many people who are victims of myocardial infarction do not call for help or differ the call, endangering themselves. These unadapted behaviors have been largely examinated, but the methods and results of the studies appear insufficient to understand what is being played intimately in patients who suffer a heart attack. We conducted a qualitative research in an epistemology of subjectivity and mobilizing the point of view in first person of patients, with the aim of exploring and understanding: (1) real-life experience of subjects during a heart attack, (2) the choices operated by victims of myocardial infarction during the crisis, (3) the mental phenomena that influence their decision to call for emergency services. We describe how identity tensions can influence patients’ decision to call a health professional. Our re-search pursues an objective of improving patient education targeting subjective phenomena that determine choices of patients during a health crisis.

La narration des experiences de vie avec la maladie aide le sujet malade a operer une reconfiguration de son existence et de son histoire, mais il existe des experiences en sante qui accedent peu au langage, et qui sont les situations de crise aigue. Celles-ci se jouent de maniere imprevue et sur des temps tres courts, ou les enjeux ne sont pas d’etre dites, racontees, mais d’etre gerees collectivement dans le but de maintenir la vie biologique. Cet article aborde les conditions de l’explicitation d’une scene de crise de sante : l’infarctus du myocarde.

Purpose The aim of this study was to determine whether dosing schedule requirements impair overall cardiovascular drug adherence. Methods A cohort study was performed with hospitalized patients at high risk of cardiovascular disease between April and September 2011. Patients were asked whether the prescribed time for taking their statin and antiplatelet drugs created any inconvenience in their daily routine and, if so, were asked to describe the reasons. Patient adherence to treatment was assessed using the Morisky Medication Adherence Scale (MMAS-8). A cohort of physicians was separately studied between June and September 2011. Physicians were interviewed to determine their dosing schedule preference when prescribing statin and anti-platelet drugs, and the rationale for choosing a specific dosing schedule. Results In the study, 103 patients and 59 physicians were included. Statins were most frequently prescribed in the evening (90%). Thienopyridines were prescribed both at lunch time (41%) and in the morning (35%). Aspirin was most frequently (65.3%) prescribed at lunch time. In total, 24.3% of patients reported being inconvenienced by their drug dosing schedule, and these subjects were less adherent to their drug regimen than those who did not report inconvenience (46.2% versus 16.7%, p = 0.014). Our results also demonstrate that there is no pharmacologic rationale for prescribing a particular drug dosing schedule for statin or anti-platelet drugs. Conclusions Physicians should assess patient convenience, when prescribing medication, to optimize treatment adherence. Copyright © 2014 John Wiley & Sons, Ltd.

Background: Ultraminiaturization of echographic systems extraordinarily provides the image “within” the clinical examination. Abdominal aorta aneurysm (AAA) diagnosis based on conventional evaluation with a dedicated operator and ultrasound machine is still controversial due to the lack of evidence of the proposed management and guidelines’ cost-effectiveness. We hypothesized that less expensive ultraportable devices could identify AAA with the same level of accuracy as conventional approaches. Methods: A first step of this study was to validate the VSCAN’s image capabilities in patients referred to the vascular Doppler laboratory. Abdominal aorta measurements were performed by an experienced physician using conventional equipment followed by a second blinded physician using the ultraportable device VSCAN. Then, 204 patients hospitalized in our cardiology institute were prospectively included for a systematic screening of AAA at bedside using the VSCAN in order to determine the feasibility and impact of fast track evaluation compared to clinical examination. Results: A strong correlation was obtained between measurements of abdominal aorta diameters using the two ultrasound systems (r = 0.98, CI: 0.97‐0.99, P < 0.001) with 100% of agreement for AAA diagnosis. In the second part of the study, visualization and measurement of the transverse diameter of the abdominal aorta was obtained in 199 patients, resulting in a feasibility of 97.5%. Among these patients, 18 AAAs were detected, which corresponds to a prevalence of 9%, whereas clinical evaluation did not detect any of them. Patients with AAA were more likely men (77.77% vs. 57.45%, P < 0.05) and hypertensive (88.8% vs. 56.9%, P < 0.05) as compared to those without AAA. Two patients with large AAA were quickly referred to the surgery department. Conclusion: Considering its low cost, diagnostic accuracy, and widespread availability, screening for AAA using an ultraportable ultrasound device such as VSCAN by an experienced physician is promising and should be used as an extension of routine physical examination in vascular patients. (Echocardiography 2012;29:285-290)

High-sensitivity C-reactive protein (hsCRP) has been reported to have a prognostic value immediately after acute coronary syndrome (ACS) and to be associated with the onset of cardiovascular (CV) events in patients with stable and unstable angina pectoris.To evaluate whether or not hsCRP levels can be used to predict future CV events in a prospective study of post-ACS patients receiving an optimized medical treatment (OMT) secondary-prevention regimen.OMT along with therapeutic and dietary education programmes were started during the acute phase, then monitored and adjusted as needed at 3 months post ACS. hsCRP was measured at 3 months after the ACS, and a global evaluation of atherosclerosis burden and risk factors were also evaluated at this time point. The study population was divided into tertiles based on their hsCRP value and followed for CV events.A total of 1202 consecutive patients with hsCRP15 mg/l were included in the study, 795 of which were followed for an average of 22 months. LDL-cholesterol, HbA(1c), waist circumference, systolic blood pressure, metabolic syndrome, tobacco consumption, and atherosclerosis burden were higher in patients in the second and third tertile of hsCRP (p0.001) than those in the first tertile, at 3 months. hsCRP level was not found to be associated with recurrence of total CV events (HR 1.29, CI 0.83-2.00) in univariate analysis. We further examined the effect of adding hsCRP levels to the Framingham risk evaluation score, and found no significant improvement the C-statistics of the Framingham risk evaluation score.hsCRP is associated with CV risk factors, but is not an independent predictor of future events in post-ACS patients receiving an OMT secondary-prevention regimen.

Summary Introduction Coronary revascularization surgery is a palliative treatment modality which should not preclude efforts to treat atherosclerosis. Aim To assess ongoing cardiovascular risk factors after coronary artery bypass surgery and develop a strategy to attenuate such factors. Methods 108 patients requiring a coronary artery bypass were included: 2 died soon after surgery and 6 were excluded for personal reasons. 100 patients were re-admitted into hospital 7 months after surgery for risk factor assessment. Eight months later, they were re-contacted by telephone (systematic follow-up) for a re-assessment. Results The population consisted of 77 men with an average age of 64±11 years. Prior to the operation, the known risk factors were: smoking 34%; HBP 61%; cholesterol 47%; diabetes 30%; obesity 25%. During their hospital stay six months after the procedure: 91% of the patients had at least one lipid metabolism abnormality. New-onset diabetes was diagnosed in 5%. Blood pressure was uncontrolled in 18% and 10% were still smoking. Patients tended to be putting on weight and 55% engaged in little or no physical activity. Systematic follow-up: lipid metabolism had normalized in 70% of the patients. Blood glucose levels were significantly lower. Blood pressure was uncontrolled in 9% and 4% were still smoking. Their weight had stabilized and 65% were engaging in moderate-to-strenuous physical activity. Conclusion Inadequate attention is paid to risk factors after coronary artery bypass surgery. A short hospital stay including a cardiovascular evaluation and education about risk factors has a positive impact on the management of atherosclerosis in the medium term.

Deformation analysis using 2-dimensional strain echocardiography can detect early systolic function abnormalities in patients with left ventricular hypertrophy. This study was designed to characterize global and regional myocardial deformation using 2-dimensional strain in professional soccer players (PSPs) compared with control subjects and patients with hypertrophic cardiomyopathy (HC). Twenty nine PSPs, 26 patients with HC, and 17 controls were investigated at rest using transthoracic echocardiography with 2-dimensional strain analysis. Radial and transverse strains were significantly higher in PSPs compared with controls, whereas longitudinal strain was lower. Compared with patients with HC, athletes had higher values for transverse, radial, and circumferential strains. In pathologic hypertrophic segments, longitudinal strain was lower in patients with HC than in PSPs. In conclusion, 2-dimensional strain can identify specific patterns of myocardial deformation in PSPs, controls, and patients with HC. It has the potential to become a routinely used method for the differentiation of athlete's heart and HC.

Metabolic syndrome (MS) consists of a cluster of metabolic and hemodynamic disorders that promote the development of atherosclerosis and increase cardiovascular morbidity/mortality. We evaluated the prevalence and characteristics of MS after acute coronary syndrome (ACS) and the effect of intensive risk factor management on the morbidity/mortality associated with MS in a therapeutic cohort; 480 consecutive patients were summoned 3 months after an ACS for cardiovascular evaluation and management. Follow-up was carried out 16 months later. At 3 months after ACS, prevalence of MS was 20.8%, as assessed by criteria of the National Cholesterol Education Program Adult Treatment Panel III and 27.7% according to the definition of the International Diabetes Federation. The most common metabolic disorders were abdominal obesity, hypertriglyceridemia, and fasting hyperglycemia. Characteristics of the initial ACS showed no significant difference between the MS and non-MS groups. Atherosclerotic extent was greater in the MS group according to Adult Treatment Panel III. At follow-up, the MS and non-MS groups achieved optimal low-density lipoprotein cholesterol and blood pressure levels. During follow-up, there was an increase in total mortality in the MS group compared with the non-MS group (5.2% vs 1.4%, p0.01) as assessed by International Diabetes Federation criteria; however, no difference in minor or major cardiovascular events was found between the 2 groups. In conclusion, MS was highly prevalent after an ACS, notably in young patients, and was not associated with a specific ACS presentation.

OBJECTIVES We sought to assess the effects of exercise on ventricular dyssynchrony in patients with normal and depressed left ventricular (LV) function. BACKGROUND Asynchronous myocardial contraction adversely influences ventricular function and is associated with a poor prognosis in heart failure. Exercise-induced changes in ventricular dyssynchrony may be an important determinant of dynamic changes in cardiac output and mitral regurgitation. METHODS A total of 65 consecutive heart failure patients and 50 matched healthy control patients underwent exercise echocardiography. Conventional and tissue Doppler parameters were measured before and during symptom-limited exercise. Left ventricular dyssynchrony was defined as the standard deviation of 12 LV segmental electromechanical delays. Analysis of the control group allowed delimitation of normal cutoff values. RESULTS In patients with normal left ventricular function, exercise did not modify the extent of LV asynchrony. In contrast, in heart failure patients, LV dyssynchrony increased by at least 20% in 34%, remained stable in 37%, and decreased by at least 20% in 29%. Moreover, 26% of heart failure patients had either exercise induction or normalization of ventricular dyssynchrony. A significant association was found between exercise-induced changes in dyssynchrony and the presence of ischemic cardiomyopathy (p < 0.05). Rest-exercise differences in ventricular dyssynchrony were correlated with changes in cardiac output and mitral regurgitation (r = -0.63 and 0.56, respectively). CONCLUSIONS In heart failure patients, exercise can alter the magnitude of ventricular dyssynchrony. Some patients have a response to exertion with induction of ventricular dyssynchrony, whereas others show normalization. Changes in ventricular dyssynchrony during exercise correlate with alterations in cardiac output and mitral regurgitation.

Objectives Recently, a novel method to measure strain from standard two-dimensional images has been developed. Our goal was to characterize global and regional systolic function abnormalities using this technique in patients with hypertrophic cardiomyopathy (HCM). Background Strain has been proposed as a sensitive tool to detect early systolic function abnormalities in HCM. However, the clinical application of conventional Doppler-derived strain has been limited by poor reproducibility and angle dependency. Methods Echocardiographic examinations were performed in 26 patients with nonobstructive HCM and 45 healthy subjects. Using a dedicated software package, bidimensional acquisitions were analyzed to measure longitudinal and transverse strain in apical views and circumferential and radial strain in parasternal short-axis view. Results Despite apparently normal left ventricular systolic function, all components of strain were significantly reduced in HCM. Average longitudinal, transverse, circumferential, and radial strain in patients with HCM and controls were −15.1 ± 6.2% versus −20.3 ± 5.6%, 23.3 ± 17.0% versus 27.2 ± 14.9%, −16.8 ± 7.1% versus 19.6 ± 5.2%, and 25.2 ± 13.9% versus 36.8 ± 17.2%, respectively (all p Conclusions Two-dimensional strain is a new simple, rapid, and reproducible method to measure different components of systolic strain. This technique identified early abnormalities in patients with HCM that have apparently normal left ventricular systolic function.

Supervised exercise programs increase physical performance in patients with peripheral artery disease (PAD). However, there are a limited number of programs, and to date they have failed to provide evidence of long-term adherence to exercise or any meaningful effect on Quality of Life (QoL). We created a program of therapeutic education and a personalized program of reconditioning exercise for patients with PAD.Patients with an ankle-brachial index (ABI) below 0.9 in at least one limb, and an absolute claudication distance (ACD) ≤500 meters, were included in the study. Quality of Life (QoL) as measured by SF-36, cardiovascular risk factors and functional parameters were evaluated at 0, 3, 6 and 12 months.Forty-six patients completed the program. Cardiovascular risks were controlled and stabilized over time. SF-36 scores improved significantly and remained stable. Initial and absolute claudication distance (ICD and ACD) as well as other functional parameters improved significantly (6 months: +138 m or +203% ICD and +139 m or +84% ACD). Ten patients (22%) did not show improvement in ICD or ACD within the first 3 months, but their SF-36 score did increase at subsequent visits. Interestingly, these patients had a significantly lower ACD at baseline.This study measured beneficial effects of an educational therapeutic program for patients with PAD. The results demonstrate a significant improvement in functional and QoL parameters during the first 3 months of coaching, and long-term persistence of the results even when patients were no longer coached.

Aims Current guidelines recommend the use of dual antiplatelet therapy (DAT) (aspirin+clopidogrel) for patients after acute myocardial infarction (MI). In relation to this, we sought to examine the adherence to this recommended treatment regimen in a population of patients admitted with MI and subsequent percutaneous coronary intervention (PCI). Methods and results A cohort study was conducted using data from the main health insurance reimbursement database of South West France. Patients hospitalised for MI in 2008 were identified, and then their reimbursement form of DAT for the subsequent 12 months was reviewed. Adherence was assessed by using the proportion of days covered by the treatment and persistence. Among the 634 patients included in the study, 34 had no reimbursement for DAT immediately after discharge. For the remaining patients, the probability of stopping DAT at least for one month was 18.6% (95% CI [15.4;21.8]) during the first three months and 49.1% (95% CI [44.9;53.2]) at 12 months, although the medication availability was 90%. Conclusions These results suggest that while this medication is available to patients, the treatment is often stopped before one year. This may account for what has been reported as "resistance" to antiplatelet therapy described in a subset of patients.

After an acute coronary syndrome (ACS), optimal medical therapy (OMT) has been shown to be effective in reducing subsequent cardiovascular (CV) events. However, even in populations that reach recommended secondary prevention goals, there is a subset of patients that experience subsequent CV events.To identify biological or clinical predictors of residual risk of CV events in post-ACS patients receiving OMT.A total of 990 post-ACS patients benefited from OMT (optimized treatment during the acute and chronic post-ACS phase, along with a therapeutic and dietary education programme). Traditional CV risk factors and atheroma disease markers (intima-media thickness measurement, carotid atheroma, peripheral arterial disease (PAD) measured by ankle brachial index, and the number of coronary arteries with a50% stenosis) were evaluated at 3 months post ACS. Cardiovascular events were recorded at follow up.At 20-month follow up,80% of the patients reached the recommended secondary prevention goals. In this population, diabetes was the only CV risk factor significantly associated with CV events in multivariate analysis including traditional risk factors (HR 1.61, p = 0.017). In multivariate analyses including CV risk factors and atheroma disease markers, only PAD remained significantly associated with CV events (HR 1.83, p = 0.04). The number of vascular beds involved was associated with poorer prognosis (HR for disease in 3-vascular-beds 3.85, p = 0.001, using disease in 1-vascular-bed as a reference group).In post-ACS patients with OMT, atheroma burden is a powerful prognostic marker of recurrent CV events, while diabetes remains the only independent marker of CV events among traditional CV risk factors.

Ultraminiaturization of echographic systems extraordinarily provides the image "within" the clinical examination. Abdominal aorta aneurysm (AAA) diagnosis based on conventional evaluation with a dedicated operator and ultrasound machine is still controversial due to the lack of evidence of the proposed management and guidelines' cost-effectiveness. We hypothesized that less expensive ultraportable devices could identify AAA with the same level of accuracy as conventional approaches.A first step of this study was to validate the VSCAN's image capabilities in patients referred to the vascular Doppler laboratory. Abdominal aorta measurements were performed by an experienced physician using conventional equipment followed by a second blinded physician using the ultraportable device VSCAN. Then, 204 patients hospitalized in our cardiology institute were prospectively included for a systematic screening of AAA at bedside using the VSCAN in order to determine the feasibility and impact of fast track evaluation compared to clinical examination.A strong correlation was obtained between measurements of abdominal aorta diameters using the two ultrasound systems (r = 0.98, CI: 0.97-0.99, P0.001) with 100% of agreement for AAA diagnosis. In the second part of the study, visualization and measurement of the transverse diameter of the abdominal aorta was obtained in 199 patients, resulting in a feasibility of 97.5%. Among these patients, 18 AAAs were detected, which corresponds to a prevalence of 9%, whereas clinical evaluation did not detect any of them. Patients with AAA were more likely men (77.77% vs. 57.45%, P0.05) and hypertensive (88.8% vs. 56.9%, P0.05) as compared to those without AAA. Two patients with large AAA were quickly referred to the surgery department.Considering its low cost, diagnostic accuracy, and widespread availability, screening for AAA using an ultraportable ultrasound device such as VSCAN by an experienced physician is promising and should be used as an extension of routine physical examination in vascular patients.

Background After an acute coronary syndrome (ACS), pharmacologic therapy and lifestyle intervention (optimal medical therapy, OMT) are efficient in reducing cardiovascular (CV) events. However, even if recommended secondary prevention goals are reached, a subset of patients still present CV events. Aim To identify biological or cardiovascular markers predicting the residual risk of CV events in post-ACS patients receiving OMT. Patients and methods 990 patients benefited from an evaluation of risk factors and atherosclerosis lesions, and optimization of long-term treatment and education. Traditional CV risk factors and atheroma disease markers (intima-media thickness (IMT), carotid atheroma, Ankle Brachial Index (ABI) and number of coronary arteries with >50% stenosis) were evaluated 3 months after ACS. CV events were recorded at follow-up (CV death, ACS, stroke, heart failure, revascularization). Results At a median follow-up of 20 months, more than 80% of the patients reached recommended prevention goals. 116 total CV events were recorded. Diabetes was the only CV risk factor significantly associated with CV events in multivariate analysis (including age, sex, hypertension, LDL cholesterol, smoking, diabetes and hsCRP); HR 1,61 (1,09–2,39), p = 0,017. In multivariate analysis including CV risk factors and atheroma disease markers (peripheral vascular disease (PVD) defined as ABI 50%, IMT >0,7 mm, 3-vessel and/or left main coronary disease), only PVD remained significantly associated with CV events; HR 1,83 (1,02–3,31), p = 0,04. The number of vascular beds involved was associated with poorer prognosis: HR for 3 vascular-beds disease 3,85 (1,72–8,63) p = 0,001, given 1 vascular-bed disease as a reference group. Conclusion In post-ACS patients with OMT, PVD and atheroma burden represent powerful prognostic markers of CV events, while diabetes remains the only independent marker of CV events among traditional CV risk factors.

We hypothesized that, based on greyscale imaging and color Doppler capabilities, a new pocket ultrasound device (PUD) could accurately record cardiologic diagnostic findings. One hundred patients referred for conventional clinical indications underwent a standard echocardiography. Subsequently, a second physician blinded to the results performed an evaluation using the PUD on the same patients. Study end-points were echocardiographic window quality; left ventricular (LV) morphology; function; hypertrophy; right ventricular, atrial and vena caval morphologies; aortic and mitral valvulopathies; and pericardial structure. Using a scale of three grades, concordance in image quality proved good with a kappa coefficient (κ) of 0.71. Concordances between systems were excellent for LV function and morphology (κ = 0.91 and 0.96). Concordance for LV hypertrophy was good (κ = 0.74). Concordances for mitral regurgitation grades were 0.90, 0.95 and 1.00, respectively. In conclusion, a new PUD enabled scanning examinations, which showed good concordance of basic and qualitative diagnostic capability to standard echocardiographic instruments.

Background Patients with acute coronary syndrome (ACS) have a high prevalence of previously unknown diabetes mellitus (DM) and impaired glucose tolerance (IGT). Both conditions represent strong risk factors for future cardiovascular events after ACS. Aim To evaluate, in non-diabetic patients in post-ACS, the effect of an early diagnosis and management of glucose metabolism abnormalities, on their persistence at 3-month. Patients and methods 271 consecutive patients were admitted for an ACS. OGTT was performed at day 2-4, and risk factors were recorded. Patients were classified following OGTT. All subjects received 3 educational courses for lifestyle modification (diet, smoking, and physical activity). Glucometabolic state was again assessed three months after the ACS. Results DM was known or diagnosed in 29.5% of the patients at admission for ACS. Patients with normal fasting glucose but classified as New Diabetes (ND, 16,7%) on OGTT shared the same risk factor profile and atheroma burden as DM patients. IGT patients (28,3%) displayed risk values in-between NGT and ND patients. Lifestyle modifications after 3 months were effective. Food records found that energy intake and fat intake decreased significantly through 3 months, with a significant increase in mono and poly unsaturated fat and a significant decrease in saturated fat. Triglycerides and metabolic syndrome were reduced, HDL cholesterol increased. As shown by OGTT results at 3 months, 70% of IGT patients at 3 days were classified as NGT at 3 months. More than 50% of the ND group at 3 days was re-classified as IGT or NGT at 3 months. Conclusion An OGTT performed after an ACS, associated with lifestyle modification and diet intervention significantly improved the short-term evolution of the glucometabolic state.

Left ventricle dysfunction and comorbidities are responsible for a large number of complications after CABG. OPCAB could be an interesting alternative for very high-risk patients. Patients were included if EuroSCORE >9, or with at least two of the following criteria, severe LV dysfunction, recent myocardial infarction (MI), terminal renal failure, lung dysfunction, PVD, BMI>30. Patients were operated using the Octopus (Medtronic) system. One hundred and twenty patients, mean age 68+/-10 years, 72% male, were operated. Mean EuroSCORE was 10.2+/-5.3, LV function 36.79+/-11.3%, recent MI 57%, renal failure 52%, COPD 44%, PVD 52%, obesity 34%. Mean graft per patient was 2.1+/-0.8. Three patients underwent secondary PTCA treatment for incomplete revascularization. Combined surgery was required for 20%. Early mortality was 3%. Intensive care unit stay was 2.7 days. Early complications were: low output syndrome 3%, MI 0.8%, stroke 0.8%, kidney support 7%. Graft patency was systematically analyzed with MCTA or angiocardiography. OPCAB strategy seems to be safe and secure in this population of very high-risk patients reducing multi-organ failure. However, long-term results are needed to confirm this strategy.

SummaryBackgroundSpeckle tracking is a new technique based on pure 2D grayscale ultrasound acquisition allowing calculation of segmental strains. To facilitate clinical application, speckle tracking has been integrated into the most recent echocardiographic systems for quick, automated evaluation of left ventricular function (Automated Function Imaging, AFI).ObjectiveTo evaluate the feasibility, calculation time, accuracy and reproducibility of global longitudinal strain (GLS) from AFI in determining LV function in comparison to reference echocardiographic and angiographic methods–whatever the operator's experience.MethodsEchocardiography was performed in 65 patients scheduled for cardiac catheterization using a Vivid 7 system. They were divided into 3 groups according to EF (>55%, 35≤EF≤55%

Introduction. - L'importance pronostique du controle des facteurs de risque et de l'adaptation therapeutique chez les patients apres un syndrome coronarien aigu (SCA) est bien etablie. Pourtant, les etudes montrent que les objectifs de prevention secondaire sont rarement atteints. Les programmes de prevention sont efficaces mais leur benefice n'est que partiellement maintenu dans le suivi a long terme. But de l'etude. - Evaluer l'efficacite d'un programme de prise en charge globale de l'atherosclerose (programme Cepta) sur le controle a long terme des facteurs de risques cardiovasculaires, sur l'adhesion au traitement et comparer les donnees sur les evenements cliniques apres un SCA a celles de la litterature. Patients et methodes. - Six cent soixante patients consecutifs ont ete hospitalises, trois mois apres la survenue d'un SCA, pour evaluation des facteurs de risques residuels, de la charge en atherome ainsi que pour beneficier d'une adaptation therapeutique et d'un programme d'education therapeutique et dietetique. Nous avons evalue l'impact de ce programme a long terme sur l'equilibre des facteurs de risque, le maintien du traitement et les evenements cliniques. Au terme d'un suivi median de 20 mois, 96,3% des patients etaient sous antiagregant, 86,0% etaient sous betabloqueur ou Verapamil, 62,4% sous inhibiteur de l'enzyme de conversion ou antagoniste des recepteurs a l'angiotensine II, 88,4% etaient sous un medicament hypocholesterolemiant et 75,5% beneficiaient d'une combinaison antiagregant betabloqueur et hypocholesterolemiant. Le controle du LDL cholesterol et de la tension arterielle etait obtenu chez plus de 81 et 71 % des patients respectivement. A 20 mois de suivi, la mortalite totale etait de 3,6% et un evenement cardiovasculaire est intervenu chez 12% des patients. En conclusion, ce programme court a distance du SCA est benefique sur la prise en charge a long terme des facteurs de risques cardiovasculaires et sur la perennite du traitement medicamenteux.

We sought to assess the effects of exercise on ventricular dyssynchrony in patients with normal and depressed left ventricular (LV) function.Asynchronous myocardial contraction adversely influences ventricular function and is associated with a poor prognosis in heart failure. Exercise-induced changes in ventricular dyssynchrony may be an important determinant of dynamic changes in cardiac output and mitral regurgitation.A total of 65 consecutive heart failure patients and 50 matched healthy control patients underwent exercise echocardiography. Conventional and tissue Doppler parameters were measured before and during symptom-limited exercise. Left ventricular dyssynchrony was defined as the standard deviation of 12 LV segmental electromechanical delays. Analysis of the control group allowed delimitation of normal cutoff values.In patients with normal left ventricular function, exercise did not modify the extent of LV asynchrony. In contrast, in heart failure patients, LV dyssynchrony increased by at least 20% in 34%, remained stable in 37%, and decreased by at least 20% in 29%. Moreover, 26% of heart failure patients had either exercise induction or normalization of ventricular dyssynchrony. A significant association was found between exercise-induced changes in dyssynchrony and the presence of ischemic cardiomyopathy (p0.05). Rest-exercise differences in ventricular dyssynchrony were correlated with changes in cardiac output and mitral regurgitation (r = -0.63 and 0.56, respectively).In heart failure patients, exercise can alter the magnitude of ventricular dyssynchrony. Some patients have a response to exertion with induction of ventricular dyssynchrony, whereas others show normalization. Changes in ventricular dyssynchrony during exercise correlate with alterations in cardiac output and mitral regurgitation.

Recently, a novel method to measure strain from standard two-dimensional images has been developed. Our goal was to characterize global and regional systolic function abnormalities using this technique in patients with hypertrophic cardiomyopathy (HCM).Strain has been proposed as a sensitive tool to detect early systolic function abnormalities in HCM. However, the clinical application of conventional Doppler-derived strain has been limited by poor reproducibility and angle dependency.Echocardiographic examinations were performed in 26 patients with nonobstructive HCM and 45 healthy subjects. Using a dedicated software package, bidimensional acquisitions were analyzed to measure longitudinal and transverse strain in apical views and circumferential and radial strain in parasternal short-axis view.Despite apparently normal left ventricular systolic function, all components of strain were significantly reduced in HCM. Average longitudinal, transverse, circumferential, and radial strain in patients with HCM and controls were -15.1 +/- 6.2% versus -20.3 +/- 5.6%, 23.3 +/- 17.0% versus 27.2 +/- 14.9%, -16.8 +/- 7.1% versus 19.6 +/- 5.2%, and 25.2 +/- 13.9% versus 36.8 +/- 17.2%, respectively (all p0.001). In patients with asymmetrical HCM, longitudinal septal strain was significantly lower than for other left ventricular segments combined: -9.2 +/- 4.7% versus -12.7 +/- 7.1% (p = 0.001). Average interobserver and intraobserver variabilities were 11% and 11.3%, respectively.Two-dimensional strain is a new simple, rapid, and reproducible method to measure different components of systolic strain. This technique identified early abnormalities in patients with HCM that have apparently normal left ventricular systolic function.

Objectif Apres un syndrome coronarien aigu (SCA), l'optimisation du traitement medical et des habitudes de vie a prouve son efficacite dans la reduction des evenements cardio-vasculaires (CV). Cependant, certains patients presentent un autre evenement CV malgre l'atteinte des cibles de prevention secondaire. Le but de l'etude est d'identifier les marqueurs predicteurs du risque residuel de patients post-SCA recevant une prise en charge optimisee, de presenter un evenement CV. Patients et methodes 990 patients avec un SCA ont beneficie d'une prise en charge intensive des facteurs de risque (FDR) CV et de la maladie atheromateuse, incluant l'optimisation des traitements et l'education therapeutique. Les FDR traditionnels et les marqueurs vasculaires (Epaisseur Intima Media (EIM), atherome carotidien, Index de Pression Systolique (IPS) et le nombre de coronaires avec une stenose > 50%) ont ete evalues 3 mois apres le SCA. Les evenements CV ont ete recueillis au suivi (Deces CV, SCA, AVC, Insuffisance cardiaque, revascularisation). Resultats Au decours d'un suivi median de 20 mois, plus de 80% des patients ont atteint les cibles de prevention secondaire. 116 evenements CV ont ete recueillis. Dans cette population, le diabete est le seul FDR qui reste associe au risque d'evenement CV en analyse multivariee (incluant âge, sexe, HTA, LDL cholesterol, tabac, diabete et CRPus) ; HR 1,61, p=0,017. En analyse multivariee incluant les FDRCV et les marqueurs vasculaires, seul l'IPS bas reste associe aux evenements CV ; HR 1,83, p=0,04. Le nombre de territoires arteriels atteints est associe au pronostic apres SCA : HR pour 3 territoires atteints 3,85, p=0,001, en comparaison avec l'atteinte d'un territoire. Conclusion Chez les patients en post-SCA ayant une prise en charge optimisee, l'arteriopathie des membres inferieurs et la charge en atherome sont des marqueurs puissants du risque CV. Le diabete reste le seul marqueur independant du risque CV parmi les FDR traditionnels.

Background The French guidelines recommend dual antiplatelet therapy after acute myocardial infarction (MI). Purpose To estimate persistence of dual antiplatelet therapy after MI. Methods A cohort study was conducted using data from the main French health insurance reimbursement database of the Aquitaine region (southwest France). Patients who have been hospitalized for MI in 2008 were first identified. Then, we looked for their reimbursement form of dual antiplatelet therapy (aspirin+clopidogrel) treatment for the following 12 months. Adherence was assessed by using two parameters: proportion of days covered by the treatment (medication availability) and persistence. The treatment persistence was the percentage of patients still treated at the end of the period. Discontinuation was defined as a minimum gap of 30 days between the theoretical end date of prescription reimbursed (based on a days’ supply) and the starting date of the next one. Results Among the 634 patients identified, 40 had no reimbursement of dual antiplatelet therapy immediately after discharge. At three month, 15.2% of the remaining patients did not buy at least one of the two treatments. They were 48.2% at 12 months although the medication availability was 90%. Conclusion Theses results suggest that while the patients have good medication availability, the treatment is often stopped before one year. At three months after MI, 20.6% of the patients were no longer treated with dual antiplatelet therapy. The results presented are likely to be an underestimation of adherence since some patients who buy their treatment, may not take it. This could explain some “resistance” described to antipletelet therapy.

BackgroundInflammation plays an important role in the initiation and progression of atherosclerosis and in the pathogenesis of acute cardiovascular (CV) events. Recent studies focused on the measurement of high sensitivity C-reactive protein (hsCRP) as predictors of CV events. hsCRP has been reported to have prognostic value immediately after ACS and to be associated with CV risk in patients with stable and unstable angina pectoris.AimTo evaluate the association of hsCRP levels with recurrent cardiovascular events in a large prospective study of stable post-ACS patients.MethodsPatients with an ACS were enrolled in our department between 2002 and 2007. HsCRP was measured at three month after the ACS together with a global evaluation of atherosclerosis burden and risk factors. Optimal medical treatment, a therapeutic and dietary education program was started during the acute phase and adjusted at 3 months.Results1202 patients with hsCRP < 15 mg/l were included and the first 795 patients were followed for an average of 22 months. 94% and 75% of the patients received a combination of b–blocker, anti- aggregates and cholesterol-lowering drugs respectively at 3 and 22 months. LDL-cholesterol, HbA1c, waist circumference, systolic blood pressure, metabolic syndrome, tobacco consumption, and atherosclerosis burden were higher in the 2nd and 3th tertile of hsCRP (p

BackgroundAfter an ischemic stroke, the risk of cardiovascular (CV) event is high. The effect of optimal control of risk factors on this high morbi-mortality has not been established in these patients.AimTo evaluate the effect of optimized secondary prevention including dietetic and therapeutic education, on CV risk factor control and CV events occurrence.Patients and method95 selected consecutive patients at high CV risk profile (>3 CVRF) benefited from a 2 days hospitalization 3 months after a stroke focused on evaluating risk factors and atherosclerosis lesions, and on optimizing treatment and education.ResultsIn this high risk population (mean age 60.4±8), we found respectively 24% and 23% of the patients with previously unknown peripheral vascular disease or coronaropathy, and 31% with left ventricular hypertrophy. At follow-up (median 684 days), 81% of the patients still received a combination of antiagregant + blood pressure drugs + statin. In term of secondary prevention goals, 73% of the patients had a normal blood pressure, 72% had a LDL

A 39-year-old woman was hospitalized for sudden massive left haemiplegia. Her only risk factor was light smoking. She was diagnosed with Crohn disease 1 month before, and treated with corticoids. Early angio-computed tomographic (CT) scan and magnetic resonance imaging (MRI) showed large sylvian cerebral ischaemia, right sylvian …

Introduction La presence d’une arteriopathie peripherique est associee a un haut risque d’evenement cardiovasculaire apres un syndrome coronarien aigu (SCA). L’effet du controle optimal des facteurs de risque et de la prescription medicamenteuse sur cette morbi-mortalite elevee n’a pas ete etabli chez ces patients. Patients et methodes Cinq cent soixante-seize patients consecutifs ont ete hospitalises 3 mois apres la survenue d’un SCA pour evaluation des facteurs de risque residuels, de la charge en atherome, ainsi que pour beneficier d’une adaptation therapeutique et d’un programme d’education therapeutique et dietetique. Nous avons compare l’impact de ce programme a long terme sur l’equilibre des facteurs de risque, le maintien du traitement et les evenements cliniques dans deux groupes (1) groupe 1 avec atteinte coronaire seule (n = 380, 73,6 %), (2) groupe 2 avec coronaropathie et arteriopathie peripherique (definie par un index de pressions systoliques chevilles-bras 1,4 et/ou une stenose carotidienne a l’echographie Doppler) (n = 136 ; 26,4 %)). Resultats Au terme d’un suivi median de 18 mois, les objectifs de prevention secondaire ont ete atteints dans les deux groupes (lipidiques, glycemiques, tension arterielle, prescription medicamenteuse). Dans cette cohorte de patients beneficiant d’une optimisation de la prevention secondaire, la presence d’une arteriopathie peripherique n’est pas associee a un sur-risque d’evenements cardiovasculaires majeurs (HR 1,09 ; 95 % CI 0,53-2,27). Le risque d’evenement cardiovasculaire est plus eleve chez les diabetiques avec arteriopathie (HR 5,31 ; 95 % CI 1,92-14,68), mais les non diabetiques avec arteriopathie (HR 1,31 ; 95 % CI 0,69-2,47), ou les diabetiques sans arteriopathie (HR 0,56 ; 95 % CI 0,22-1,46) ne presentent pas un risque superieur aux patients post-SCA sans diabete et sans arteriopathie. Conclusion Le pronostic cardiovasculaire des patients avec arteriopathie est comparable a ceux qui ont une atteinte coronaire seule quand les objectifs de prevention secondaire sont atteints, sauf chez les diabetiques avec arteriopathie.

Summary Background Peripheral vascular disease (PVD) is associated with a high risk of cardiovascular events after an acute coronary syndrome (ACS). The impact of suboptimal risk-factor control and drug prescription on morbidity and mortality rates in patients with PVD following an ACS remains to be established. Aims To assess whether a global atherosclerosis management programme and optimal secondary prevention could benefit high-risk PVD patients after an ACS. Methods A total of 851 ACS patients underwent an intensified intervention focusing on evaluating risk factors and atherosclerosis lesions, and on optimizing treatment and education. We compared its impact on long-term risk factors, medication observance and cardiovascular outcomes in patients with coronary artery disease (CAD) alone ( n = 715, 84.0%) and with both CAD and PVD ( n = 136). Results At a median follow-up of 18.6 months, both groups reached recommended secondary prevention goals and showed no significant differences in rates of drug prescription. PVD was not associated with minor cardiovascular events (hazard ratio [HR] 1.32, 95% confidence interval [CI] 0.57–3.02) but remained independently associated with major (HR 2.15, 95% CI 1.12–4.13) and total (HR 1.76, 95% CI 1.05–2.93) cardiovascular events. Compared to patients with CAD alone, this risk was significantly higher in CAD patients with both PVD and diabetes (HR 2.87, 95% CI 1.52–5.43), but not in PVD patients without diabetes (HR 1.35, 95% CI 0.71–2.56) or diabetic patients without PVD (HR 1.11, 95% CI 0.68–1.81). Conclusion Despite optimization of risk-factor control and drug prescription after ACS, patients with both PVD and diabetes carry a 2.9-fold higher risk of cardiovascular events at 18-month follow-up versus patients with CAD alone. This excess risk was not significant in PVD patients without diabetes or in diabetic patients without PVD.