[Epidemiology of acute coronary syndromes in France and in Europe]

In France, the incidence of myocardial infarctions leading to hospitalisations can be estimated between 60,000 and 65,000 each year. With the addition of cases of unstable angina, about 80,000 to 100,000 hospital stays each year are caused by acute coronary syndromes. Cases of out-of-hospital cardiac arrest of ischaemic origin should also be taken into account when estimating the annual incidence of myocardial infarction. In Europe, a North-South gradient, and even more an East-West gradient is observed for the incidence of ischaemic heart disease, with the highest figures found in central and eastern European countries. A consistent trend to a decrease in the incidence of myocardial infarction is observed on both sides of the Atlantic. In parallel, progress in the management of acute coronary syndromes has led to a marked decrease in early case fatality rates. Overall, these trends explain the spectacular decrease in cardiovascular mortality observed over the past 25 years in most European countries. Acute coronary syndromes, however, remain severe clinical conditions, which carry a high mid-term and long-term morbi-mortality and deserve further efforts to develop new therapeutic tools.

[Drug-eluting stents: do we respect the on-label use in our daily practice?]

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

Structural biology of bacterial secretion systems in gram-negative pathogens--potential for new drug targets

Gram-negative bacteria have evolved diverse secretion systems/machineries to translocate substrates across the cell envelope. These various machineries fulfil a wide variety of functions but are also essential for pathogenic bacteria to infect human or plant cells. Secretion systems, of which there are seven, utilize one of two secretion mechanisms: (i) the one-step mechanism, whereby substrates are translocated directly from the bacterial-cytoplasm to the extracellular medium or into the eukaryotic-target cell; (ii) the two-step mechanism, whereby substrates are first translocated across the bacterial-inner membrane; once in the periplasm, substrates are targeted to one of the secretion systems that mediate the transport across the outer membrane and the release outside the bacterial cell. This review describes in details the main structural features of these secretion systems. Structural biology offers the possibility to understand the molecular mechanisms at play in the various secretion systems. It also helps to design specifically drugs that can block these machineries and thus attenuate the virulence of pathogenic bacteria.

[Case report and review of a voluminous right atrial myxoma revealed by heart failure]

Right atrial myxoma is a rare disease and its clinical presentation is not specific. The usual mode of revelation is heart failure. The most frequent complications are pulmonary embolism and atrioventricular valve obstruction by the tumor. A 49-year-old woman was admitted to intensive care unit for heart failure. The echocardiogram showed a voluminous right atrial myxoma, appending to the interatrial septum. Its surgical excision under extracorporeal circulation was successfully performed. Histology confirmed the final diagnosis of myxoma. No complication was observed at 6 months follow-up.

[Spinal cord ischaemia and preoperative clopidogrel withdrawal in an arteriosclerotic patient]

We report the case of a motor impairment associated with bladder dysfunction several days after clopidogrel withdrawal in an arteriosclerotic woman scheduled for thoracotomy under general and thoracic epidural anaesthesia. Even if spinal artery syndrome may have a lot of aetiologies, we believe in a direct link between clopidogrel withdrawal and medulla ischaemia.

[Impact of patient adherence to recommended medications on outcomes in populations with coronary artery disease]

Prescribing recommended medications is associated with improved outcomes in coronary artery disease patients. Likewise, adherence to prescribed medications, which frequently appears far from optimal, is significantly correlated with improved survival in "real world" observational databases. The present article reviews currently available data on the impact of medication adherence on outcomes in patients with coronary artery disease.

[Gp IIb/IIIa receptor antagonists in acute coronary syndromes with no ST elevation]

Gp IIb/IIIa receptor antagonists have been the subject of much work in patients presenting with acute coronary syndrome with no ST elevation (ACS ST-). The initial studies (PRISM, PRISM-PLUS, PURSUIT, PARAGON, CAPTURE, GUSTO IV-ACS) were performed at the end of the 1990s and universally showed a significant reduction in an endpoint combining death and myocardial infarction, especially in patients with an elevation of troponin and treated by angioplasty. However, these studies were performed at a time when clopidogrel was not being used regularly for this indication. Four randomised studies have recently re-evaluated the significance of Gp IIb/IIIa blockers prescribed either on admission to coronary intensive care (ELISA-2, PRACTICE) or in the coronary angiography suite during angioplasty (ADVANCE, ISAR-REACT 2) in patients presenting with ACS ST- pre-treated with clopidogrel in association with aspirin and heparin. The results of these studies suggest that Gp IIb/IIIa blockers initiated at the start of angioplasty significantly reduce an endpoint combining death, myocardial infarction and the need for emergency revascularisation. On the other hand, studies in which Gp IIb/IIIa blockers are initiated in coronary intensive care have been negative, but they have only been carried out on small numbers. The results of the ACUITY study comparing bivalirudin and Gp IIb/IIIa blockers in this context have recently been published. Bivalirudin seems to compare well with Gp IIb/IIIa blockers in terms of ischemia, but it significantly reduces the occurrence of hemorrhagic events.

[Endovascular treatment of aortic isthmus ruptures: medium term results]

Despite an improvement in the surgical management of aortic isthmus ruptures, the observed morbidity and mortality rates remain high. The use of aortic endoprostheses could improve these results, but there are not yet many medium term studies on ruptures of the isthmus. Between January 2000 and December 2005, we treated endovascularly 9 patients (7 males and 2 females) presenting with a rupture of the aortic isthmus, acute in 8 of them and chronic in one case. The average age was 46 years. All of the patients presented with significant traumatic co-morbidity. Ten endoprostheses were used in these 9 patients, and no immediate conversion was necessary. Complete excision of the lesions lasted on average 112 +/- 27 min and there were no per-operative deaths. Hospital mortality was 22% (2 patients: multiple organ failure on day 3, and a CVA on day 10). The mean length of hospital stay was 16 +/- 20 days. The mean follow up of the 7 surviving patients was 38 +/- 17 months. No complications relating to the endoprostheses were reported. In all of the patients an almost complete disappearance of lesions on CT scan was noted: by 6 months for the acute ruptures and at 1 year for the chronic rupture.

CONCLUSION

the medium term results of endovascular treatment of isthmus ruptures are good.

[Risk stratification of acute coronary syndromes]

In acute coronary syndromes, risk stratification is essential, particularly in those without ST-elevation, and is based upon clinical and biological markers. Among them, recent and repeated anginal attacks, ST-segment modifications on admission electrocardiogram, and increased markers of myonecrosis (particularly increased troponine levels) are strong predictors of untoward outcome. These variables can be used to construct risk scores, among which the TIMI and GRACE scores are the most widely used. These scores may prove helpful to define the optimal diagnostic and therapeutic management of the patients.

Magnetic resonance imaging of ruptured plaques in the rabbit with ultrasmall superparamagnetic particles of iron oxide

BACKGROUND

Magnetic resonance imaging (MRI) enhanced with ultrasmall superparamagnetic particles of iron oxide (USPIO) has previously been evaluated in hyperlipidemic rabbits. The aim of this study was therefore to compare USPIO in ruptured and non-ruptured arteries in an atherosclerotic rabbit model.

METHODS

Atherosclerotic-like lesions were induced by the combination of endothelial abrasion and high-cholesterol diet in iliac rabbit arteries (n = 16). Rupture of atherosclerotic lesions was realized by oversized balloon angioplasty in one iliac artery, whereas the contralateral artery was used as control. USPIO (ferumoxtran-10: 1 mmol Fe/kg) was administered immediately (n = 10) or 28 days (n = 6) after injury. MRI and histological analysis were performed 7 and 35 days after injury and in control arteries.

RESULTS

In vivo MRI analysis showed extended susceptibility artifact with transluminal signal loss in all ruptured arteries 7 days after injury. In contrast, hyposignal was reduced 35 days following injury (i.e. after healing), and absent in non-ruptured arteries. Similarly, histological analysis of iron uptake was significantly increased 7 days after injury compared to healed-ruptured and control arteries.

CONCLUSIONS

Accumulation ofUSPIO is significantly increased in ruptured as compared to non-ruptured arteries in the atherosclerotic rabbit model.

19F High Magnetic Field NMR Study of β-ZrF4 and CeF4: From Spectra Reconstruction to Correlation between Fluorine Sites and 19F Isotropic Chemical Shifts

High magnetic field and high spinning frequency one- and two-dimensional one-pulse MAS 19F NMR spectra of beta-ZrF4 and CeF4 were recorded and reconstructed allowing the accurate determination of the 19F chemical shift tensor parameters for the seven different crystallographic fluorine sites of each compound. The attributions of the NMR resonances are performed using the superposition model for 19F isotropic chemical shift calculation initially proposed by Bureau et al. (Bureau, B.; Silly, G.; Emery, J.; Buzaré, J.-Y. Chem. Phys. 1999, 249, 85-104). A satisfactory reliability is reached with a root-mean-square (rms) deviation between calculated and measured isotropic chemical shift values equal to 1.5 and 3.5 ppm for beta-ZrF4 and CeF4, respectively.

Bypassing the emergency room reduces delays and mortality in ST elevation myocardial infarction: the USIC 2000 registry

OBJECTIVE

To study the impact on outcomes of direct admission versus emergency room (ER) admission in patients with ST-segment elevation myocardial infarction (STEMI) DESIGN: Nationwide observational registry of STEMI patients

SETTING

369 intensive care units in France.

INTERVENTIONS

Patients were categorised on the basis of the initial management pathway (direct transfer to the coronary care unit or catheterisation laboratory versus transfer via the ER).

MAIN OUTCOME MEASURES

Delays between symptom onset, admission and reperfusion therapy. Mortality at five days and one year.

RESULTS

Of 1204 patients enrolled, 66.9% were admitted direct and 33.1% via the ER. Bypassing the ER was associated with more frequent use of reperfusion (61.7% v 53.1%; p = 0.001) and shorter delays between symptom onset and admission (244 (interquartile range 158) v 292 (172) min; p < 0.001), thrombolysis (204 (150) v 258 (240) min; p < 0.01), hospital thrombolysis (228 (156) v 256 (227) min, p = 0.22), and primary percutaneous coronary intervention (294 (246) v 402 (312) min; p < 0.005). Five day mortality rates were lower in patients who bypassed the ER (4.9% v 8.6%; p = 0.01), regardless of the use and type of reperfusion therapy. After adjusting for the simplified Thrombolysis in Myocardial Infarction (TIMI) risk score, admission via the ER was an independent predictor of five day mortality (odds ratio 1.67, 95% confidence interval 1.01 to 2.75).

CONCLUSIONS

In this observational analysis, bypassing the ER was associated with more frequent and earlier use of reperfusion therapy, and with an apparent survival benefit compared with admission via the ER.