Risk for Recurrent Venous Thromboembolism in Patients With Subsegmental Pulmonary Embolism Managed Without Anticoagulation : A Multicenter Prospective Cohort Study

BACKGROUND

The incidence of pulmonary embolism has been increasing, but its case-fatality rate is decreasing, suggesting a lesser severity of illness. The clinical importance of patients with pulmonary embolism isolated to the subsegmental vessels is unknown.

OBJECTIVE

To determine the rate of recurrent venous thromboembolism in patients with subsegmental pulmonary embolism managed without anticoagulation.

DESIGN

Multicenter prospective cohort study. (ClinicalTrials.gov: NCT01455818).

SETTING

Eighteen sites between February 2011 and February 2021.

PATIENTS

Patients with isolated subsegmental pulmonary embolism.

INTERVENTION

At diagnosis, patients underwent bilateral lower-extremity venous ultrasonography, which was repeated 1 week later if results were negative. Patients without deep venous thrombosis did not receive anticoagulant therapy.

MEASUREMENTS

The primary outcome was recurrent venous thromboembolism during the 90-day follow-up period.

RESULTS

Recruitment was stopped prematurely because the predefined stopping rule was met after 292 of a projected 300 patients were enrolled. Of the 266 patients included in the primary analysis, the primary outcome occurred in 8 patients, for a cumulative incidence of 3.1% (95% CI, 1.6% to 6.1%) over the 90-day follow-up. The incidence of recurrent venous thromboembolism was 2.1% (CI, 0.8% to 5.5%) and 5.7% (CI, 2.2% to 14.4%) over the 90-day follow-up in patients with single and multiple isolated subsegmental pulmonary embolism, respectively. No patients had a fatal recurrent pulmonary embolism.

LIMITATION

The study was restricted to patients with low-risk subsegmental pulmonary embolism.

CONCLUSION

Overall, patients with subsegmental pulmonary embolism who did not have proximal deep venous thrombosis had a higher-than-expected rate of recurrent venous thromboembolism.

PRIMARY FUNDING SOURCE

Heart and Stroke Foundation of Canada and French Ministry of Health Programme Hospitalier de Recherche Clinique.

Use of ADAM-C and CHA2DS2-VASc scores to predict complex aortic atheroma after brain ischemia: A prospective observational study

BACKGROUND AND AIMS

Complex aortic atheroma (CAA) is a common cause of acute brain ischemia (BI), including ischemic stroke (IS) and transient ischemic attack (TIA), and is associated with recurrence. The CHA2DS2-VASc score is a useful tool for predicting stroke in patients with atrial fibrillation (AF), and can also predict cardiovascular events in other populations, including non-AF populations. The ADAM-C score is a new risk score for predicting the diagnostic yield of transesophageal echocardiography (TEE) after BI. We aimed to evaluate the ability of CHA2DS2-VASc and ADAM-C scores to predict CAA after BI.

METHODS

This prospective, multicenter, observational study included 1479 patients aged over 18 years who were hospitalized for BI. CAA was defined as the presence of one or more of the following criteria: thrombus, ulcerated plaque, or plaque thickening ≥ 4 mm.

RESULTS

CAA was diagnosed in 216 patients (14.6%). CHA2DS2-VASc and ADAM-C scores were significantly higher in the CAA group versus the non-CAA group (P < .0001 for both). The CHA2DS2-VASc and ADAM-C scores appear to be good predictors of CAA (AUC 0.699 [0.635, 0.761] and 0.759 [0.702, 0.814], respectively). The sensitivity, specificity, predictive positive value (PPV), and negative predictive value (NPV) of the scores for detecting CAA were 94%, 22%, 17%, and 96%, respectively, for a CHA2DS2-VASc score < 2, and 90%, 46%, 22%, and 96%, respectively, for an ADAM-C score < 3 CONCLUSIONS: CHA2DS2-VASc and ADAM-C scores are able to predict CAA after BI. CHA2DS2-VASc < 2 and ADAM-C < 3 both have an interesting NPV of 96%.

Bleeding risk with rivaroxaban compared with vitamin K antagonists in patients aged 80 years or older with atrial fibrillation

OBJECTIVE

Direct oral anticoagulants have been evaluated in the general population, but proper evidence for their safe use in the geriatric population is still missing. We compared the bleeding risk of a direct oral anticoagulant (rivaroxaban) and vitamin K antagonists (VKAs) among French geriatric patients with non-valvular atrial fibrillation (AF) aged ≥80 years.

METHODS

We performed a sequential observational prospective cohort study, using data from 33 geriatric centres. The sample comprised 908 patients newly initiated on VKAs between September 2011 and September 2014 and 995 patients newly initiated on rivaroxaban between September 2014 and September 2017. Patients were followed up for up to 12 months. One-year risks of major, intracerebral, gastrointestinal bleedings, ischaemic stroke and all-cause mortality were compared between rivaroxaban-treated and VKA-treated patients with propensity score matching and Cox models.

RESULTS

Major bleeding risk was significantly lower in rivaroxaban-treated patients (7.4/100 patient-years) compared with VKA-treated patients (14.6/100 patient-years) after multivariate adjustment (HR 0.66; 95% CI 0.43 to 0.99) and in the propensity score-matched sample (HR 0.53; 95% CI 0.33 to 0.85). Intracerebral bleeding occurred less frequently in rivaroxaban-treated patients (1.3/100 patient-years) than in VKA-treated patients (4.0/100 patient-years), adjusted HR 0.59 (95% CI 0.24 to 1.44) and in the propensity score-matched sample HR 0.26 (95% CI 0.09 to 0.80). Major lower bleeding risk was largely driven by lower risk of intracerebral bleeding.

CONCLUSIONS

Our study findings indicate that bleeding risk, largely driven by lower risk of intracerebral bleeding, is lower with rivaroxaban than with VKA in stroke prevention in patients ≥80 years old with non-valvular AF.

482Direct oral anticoagulant rivaroxaban in very old and frail patients: A one-year prospective follow-up of a large-scale cohort (SAFIR-AC)

Background/Introduction

Age is one of the strongest predictors/risk factors for ischemic stroke in subjects with atrial fibrillation (AF). Direct oral anticoagulants (DOACs) have been shown to be effective in the prevention of this condition; however, clinical evidence on bleeding risk with this therapeutic strategy in very old and frail geriatric patients is poor.

Purpose

To assess bleeding risk in French geriatric patients aged ≥80 years and diagnosed with AF newly treated with rivaroxaban.

Methods

Subjects, presenting to one of 33 geriatric centers, with non-valvular AF and recent initiation of a treatment with rivaroxaban were enrolled in the study and followed-up every 3 months for 12 months. Clinical and routine laboratory data and evaluation scores, such as HAS-BLED, HEMORR2HAGES, ATRIA, and CHA2DS2-VASc, as well as comprehensive geriatric evaluation were reported. Major bleeding, as defined in ROCKET AF study, was reported at each visit, and this primary outcome was adjudicated by an independent committee. Results of this cohort were compared with findings from a similar cohort treated with vitamin K antagonists (VKAs) from the same centers (n=924).

Results

A total of 1045 subjects were enrolled in the study of whom 995 (95%) had a one-year follow-up (analyzed population). The mean (standard deviation (SD)) age was 86.0 (4.3) years, with the majority of patients being female (61%), 23% aged 90 years or older, and 48% having an estimated glomerular filtration rate (eGFR) <50 mL/min. The main comorbidities were hypertension in 77% of subjects, malnutrition 49%, anemia 43%, dementia 39%, heart failure 36%, and falls 27%. The mean (SD) score for CHA2DS2-VASc was 4.8 (1.4), HAS-BLED 2.4 (0.9), Mini-Mental State Examination (MMSE) 21.5 (6.9), Activities of Daily Living (ADL) 4.4 (1.9), and Charlson Comorbidity Index 6.7 (2.0). The one-year rate of major bleeding events was 6.4% of which 0.8% were fatal and 1.1% intracranial hemorrhages (ICH), whereas the one-year rate of ischemic stroke was 1.4% and all-cause mortality 17.9%. Computed with VKA cohort findings and adjusted for age, gender, eGFR and Charlson score, this would result in a hazard ratio of 0.54 (95% confidence interval [CI], 0.38 to 0.78) for major bleeding, 0.36 (0.17 to 0.76) for ICH, 0.62 (0.29 to 1.33) for ischemic stroke, and 0.82 (0.65 to 1.02) for all-cause mortality, in favor of rivaroxaban.

Conclusions

This is the first large-scale prospective study in geriatric population in AF subjects treated with DOAC (rivaroxaban) Major bleeding risk appeared higher in very old than younger population, however major bleeding and ICH rates were significantly lower with rivaroxaban than with VKAs when used in the same geriatric population. This study indicates that Rivaroxaban can be used in very old and frail patients for the treatment of non-valvular AF.

Acknowledgement/Funding

Unrestricted grant from Bayer

ADAM-C score: New risk score for predicting diagnostic yield of transesophageal echocardiography after cerebral ischemia

BACKGROUND AND AIM

The clinical utility of transesophageal echocardiography (TEE) after brain ischemia (BI) remains a matter of debate. We aimed to evaluate the clinical impact of TEE and to build a score that could help physicians to identify which patients should better benefit from TEE.

METHODS

This prospective, multicenter, observational study included patients over 18 years old, hospitalized for BI. TEE findings were judged discriminant if the results showed important information leading to major changes in the management of patients. Most patients with patent foramen ovale were excluded. Variables independently associated with a discriminant TEE were used to build the prediction model.

RESULTS

Of the entire population (1479 patients), 255 patients (17%) were classified in the discriminant TEE group. Five parameters were selected as predictors of a discriminant TEE. Accordingly, the ADAM-C score could be calculated as follows: Score = 4 (if age ≥60) + 2 (if diabetes) + 2 (if aortic stenosis from any degrees) + 1 (if multi-territory stroke) + 2 (if history of coronary artery disease). At a threshold lower than 3, the sensitivity, specificity, positive predictive value, and negative predictive value (NPV) of detecting discriminant TEE were 88% (95% CI 85-90), 44% (95% CI 41-47), 21% (95% CI 19-27), and 95% (95% CI 94-97), respectively.

CONCLUSION

A simple score based on clinical and transthoracic echocardiographic parameters can help physicians to identify patients who might not benefit from TEE. Indeed, a score lower than 3 has an interesting NPV of 95% (95% CI 94-97).

Progression of early repolarization patterns at a four year follow-up in a female flight crew population: Implications for aviation medicine

BACKGROUND

To assess the prevalence, the appearance, and the distribution, as well as the fluctuation over time of early repolarization patterns after four years in a female population derived from the French aviation sector.

METHODS

This was a retrospective longitudinal study from 1998 to 2010 of a population of female employees who received a full clinical examination and an electrocardiogram (ECG) upon their recruitment and after a period of four years.

RESULTS

A total of 306 women were included (average of 25.87 ± 3.3 years of age). The prevalence of early repolarization was 9.2%. The most common appearance was J-point slurring for 64.3% (i.e. 20/28 subjects) that occurred in the inferior leads for 28.6% (i.e. 8/28 subjects). After four years, the prevalence was 7.5%, with a regression of this aspect in five of the subjects. There were no changes in the ECG in terms of the distribution and the appearance among the 23 subjects for whom the aspect persisted. Over the course of this four year period all of the subjects remained asymptomatic.

CONCLUSIONS

Early repolarization in this largely physically inactive female population was common, and it fluctuated over time. At present, no particular restrictions can be placed on asymptomatic flight crew who exhibit this feature in the absence of a prior medical history for heart disease.

[Cannabis "bong": A frequent, original and dangerous way of consumption]

The bong is a water pipe craft, used to smoke tobacco or cannabis. The benefit of consuming cannabis as a "bang" is based on the intensity and speed of the effect. The cannabis intoxication can then be associated with disorders of sensory functions, the type of distortion of perceptions or hallucinations, often accompanied by intense anxiety. Bong cannabis consumption appears to be responsible for specific side effects (especially hemoptysis), possibly related to the importance of inhalation of products of combustion of cannabis and combustion of plastic parts used in its manufacture.

Recurrent systemic embolism caused by descending thoracic aortic mural thrombus in a young cannabis abuser

Aortic mural thrombi are a rare cause of peripheral arterial embolic events. We report the case of a young man with prior history of Buerger's disease and marijuana abuse. He presented visceral infarctions due to descending thoracic aortic mobile pedunculated thrombus with complex atherosclerosis. Cannabis was stopped, intravenous heparin and vitamin K antagonist (VKA) therapies were administered. At 3-month follow-up, he was free of thromboembolic events and aortic imaging normalized. Optimal treatment of embolized aortic thrombus remains controversial, but systemic anticoagulation is widely accepted as the first-line therapy. <Learning objective: Arteritis due to cannabis has been well reported and arterial proximal atherosclerosis lesions may also be present. Aortic mural thrombi predominantly occur in pathological aortic segments at the site of atherosclerotic plaque. As shown in this case, short-term favorable outcomes can be obtained with oral anticoagulation and the interruption of marijuana abuse.>.

[Diagnosis of a systolic murmur among young asymptomatic patient: An assessment of professional practices for the expertise in military medicine]

The finding of a systolic heart murmur is common in medical military practice. Albeit often benign among young healthy adults, it can reveal a valvular or a cardiac disease, which could worsen during workout or expose to risk of a sudden death. This study aims to evaluate the diagnostic efficiency of the military general practitioner when discovering a systolic murmur among young asymptomatic patients.

MATERIALS AND METHODS

During one year, this study involved all the general practitioners of the medical military centres of Brittany and the cardiologists of the military hospital in Brest. It prospectively enrolled a cohort of all military asymptomatic patients under 40, without any underlying known heart condition. Military general practitioners listed, thanks to an anonymous form, the main features of the systolic murmur and of the ECG and proposed an auscultatory diagnosis: innocent or organic murmur. Then cardiologists did the same and finally performed a transthoracic echocardiography giving the diagnosis.

RESULTS

Fifty-eight patients were referred, 5 not meeting the inclusion criteria. Of the 53 patients included, military general practitioners found 46 innocent murmurs and 7 organic ones. Cardiologists found 51 innocent murmurs and 2 organic. Transthoracic echocardiography just took on one organic murmur (linked with a bicuspid aortic valve), spotted by the specialist, though judged innocent by the general practitioner.

DISCUSSION

Most of innocent murmurs diagnosed by general practitioners (45/46) were confirmed. Regarding the seven organic murmurs, the main selected criteria (intensity over 3, orthostatic persistence, diffuse irradiation) are mostly in accordance with the literature, proving right medical instincts. Authors propose a practical management of systolic murmurs among asymptomatic young patients.

CONCLUSION

Military general practitioners seem to master symptoms of organic murmur. This assessment argues for a promotion of a holistic clinical examination, which will help not only to rationalize the use of transthoracic echocardiography in economic terms but also to value the medical expertise.

[Echographic diagnosis of systolic murmur among 280 young French militaries. Implications for the expertise in military medicine]

Clinically discovering a systolic murmur is frequent among the young military population. When this murmur does not sound benign, a transthoracic echocardiography (TTE) is made to detect any cardiopathy, which could cause sudden cardiac death. The aim of this study was to evaluate the interest of systematic TTE in the assessment of any cardiac systolic murmur (CSM) among militaries.

METHODS

We ran a retrospective monocentric study in the "Clermont-Tonnerre" military hospital in Brest. We included all patients sent for TEE, aged 15 to 30 years old, from the 1st January 2010 until the 31st July 2013.

RESULTS

Two hundred and eighty TTES assessing CSM were performed. We found 28/280 (10%) echocardiographic abnormalities: 13 were bicuspid aortic valves (4.6%), 6 were ventricular septal defects (2.15%), 3 were atrial septal defects (1.07%), 4 were mild mitral regurgitations (1.43%), one mild pulmonary stenosis (0.35%) and one aortic stenosis (0.35%). No hypertrophic cardiomyopathy was found. Concerning military expertise, 11 (3.92%) patients among these 28 with abnormal TEE were considered unfit for work or "fit for work with limitations".

CONCLUSION

Assessing a cardiac systolic murmur with TEE lead to the diagnosis of a cardiomyopathy in 10% of the case. This study enhances the importance of systematic TEE when a CSM is detected in the young military, in order to determine if those soldiers can still fulfill their military duty.

Evolution of Early Repolarization Patterns after 5 Years in a Military Population at Low Cardiovascular Risk and Practical Implications in Military Medical Expertise

BACKGROUND

The French military population is a young and athletic population with a high prevalence of early repolarization patterns (ERP) compared to the general population. Screening of military officers at risk of sudden death (SD) is a priority in military medical expertise. The aim of our study was to evaluate the prevalence of ERP and its evolution over a period of 5 years in a specific asymptomatic population, free of heart disease and cardiovascular risk factors.

METHODS

From March to December 2008, we prospectively collected the electrocardiograms (ECGs) of military officers enlisted into the submarine forces of France. For 5 years (until 2012), the military officers included in the study underwent a clinical examination twice per year. A new ECG was carried out 5 years after the initial one.

RESULTS

A total of 250 male subjects were included (mean age 22.87 ± 0.5 years). The prevalence of ERP was 19.2%. The most common appearance was an elevation of a slurring type J point (31/48 or 64.5%) in inferolateral leads (18/48 or 37.8%). After 5 years, the prevalence of ERP was identical to that of the previous period (19.2%) with no change in appearance, distribution, and amplitude in 47 subjects (97.9%). Repolarization changed in two patients (one occurrence of ERP and one disappearance). During the 5 years of follow-up, the subjects remained asymptomatic

CONCLUSION

ERP is common in our population of young, athletic, and asymptomatic military officers and changes little in 5 years.

[Contribution of cardiac MRI in the initial evaluation and follow-up of myocarditis mimicking acute coronary syndrome: a series of 43 patients]

AIMS

The diagnosis of acute myocarditis is complex, especially when the clinical presentation mimics an acute coronary syndrome. This condition may promote the progression to dilated cardiomyopathy and the occurrence of severe arrhythmias. A reassessment integrating a cardiac MRI at three months after the acute episode could help identify patients with a poor prognosis.

PATIENTS AND RESULTS

This prospective series of 43 consecutive patients hospitalised for acute myocarditis included 36 men and seven women, with a mean age of 32 years, with no indication of heart failure. All patients presented elevated levels of troponin I. Echocardiography showed moderate left ventricular dysfunction in six cases and segmental wall motion abnormalities in 22 cases. After gadolinium injection, a subepicardial late enhancement was observed in 39 cases. Three months after the acute episode, all patients were asymptomatic. The echocardiography and laboratory tests were normal. In 23 cases, the MRI showed persistence of the late enhancement without segmental wall motion abnormality. After a mean follow-up of three years, one patient was lost to follow-up and only one suffered a heart failure revealing a dilated cardiomyopathy complicated by ventricular arrhythmias.

CONCLUSION

On admission, the subepicardial localisation of late enhancement in the cardiac MRI is reliable criteria for the diagnosis of acute myocarditis, enabling to rule out an acute coronary syndrome. During follow-up, the persistence of late enhancement has no impact on prognosis. In this series, after a mean follow-up of three years, it was not associated with clinical or paraclinical abnormalities, except in one patient.

[Practical conduct for patients with a lonely hypoxemia at rest or during exercise]

INTRODUCTION

Hypoxemia is a decrease in blood oxygen partial pressure. This work aims at presenting a practical conduct for patients with a lonely hypoxemia at rest or during exercise, defined by the absence of dyspnea at rest, obvious clinical or radiographic abnormality.

STATE OF THE ART

Diagnostic tools available to the clinician are clinical examination, CT scan, echocardiography, hyperoxia test, trans cranial ultrasound and lung scintigraphy. This work proposes a practical diagnostic approach, with a main role of chest CT.

PERSPECTIVES

Work is underway to determine more precisely the place of echocardiography for the diagnosis of intra or extra cardiac shunts.

CONCLUSIONS

The finding of a lonely hypoxemia requires careful diagnostic approach to quickly rule out potentially serious causes and not to disregard the rare causes.

[Systematic implementation of transthoracic echocardiography, transesophageal echocardiography and 24-hour Holter ECG for the detection of cardiac sources of embolism in patients with stroke or transient ischemic attack. A retrospective study of 220 patients]

INTRODUCTION

Embolism of cardiac origin accounts for around 20% of ischemic strokes. ECG and transthoracic echocardiography (TTE) are commonly obtained during the evaluation of patient of ischemic stroke but specific indications for the transesophageal (TEE) echocardiography and 24-hour Holter ECG (Holter) remain uncertain.

OBJECTIVES

The aim of this study is to report the contribution of TTE, TEE and Holter performed as a routine during the evaluation of patients with ischemic stroke (IS) or transient ischemic attack (TIA).

METHODS

This is a retrospective single-center study of 220 patients hospitalized between 1st January 2007 and 31st December 2010 for a first IS or TIA.

RESULTS

One hundred and forty-three IS and 77 TIA are identified. The average age of patients was 66 years (18-88 years). TTE/TEE/24-hour Holter allowed the diagnosis of cardiac sources of embolism in 135 patents (61.3%). TTE/TEE identified potential source of cardiogenic embolism in 126 patients (52.2%). Twenty four-hour Holter ECG tracked supraventricular arrhythmia in 15 patients (6.7%), 9 (4%) which had non-contributory ultrasound assessment.

CONCLUSION

The systematic implementation of TTE/TEE/Holter is useful for identifying potential sources of cardiogenic embolism. The performance of TEE remains above the TTE. Holter should be recommended because it is a cost effective and non-invasive tool.

Prevalence of early repolarization patterns in a French military population at low cardiovascular risk: implications for preventive medicine

BACKGROUND

Early repolarization pattern (ERP) associated with a risk of sudden death has recently been described. Very few studies have examined the prevalence of this pattern in a military population characterized by a predominance of young, active male subjects. Therefore, the main objective of this study was to evaluate the prevalence of ERP in a healthy military population free of heart disease but subjected to extreme and potentially arrhythmogenic physical activity.

METHODS

This prospective, multicenter study was carried out from November 2010 to November 2011 and included 746 individuals undergoing ECG screening; 466 were men (62.4%) and 280 were women (37.5%). Each ECG was interpreted twice by trained cardiologists.

RESULTS

The total prevalence of ERP was 13.8% (103/746); 16% (46/280) in women and 12% (57/466) in men (P > 0.05). It declined with age and the pattern of slurring in inferior location was the most common. Heart rate was significantly lower in military officers with ERP.

CONCLUSIONS

ERP was commonly found in this healthy military population. Preventing the risk of sudden death in this population requires systematic ECG screening, medical history analysis and clinical examination to identify symptomatic patients.

An example of extreme cardiology: chest pain on the high seas and helicoptered medical evacuations: the French Navy experience

Medicalized high sea rescue is very different from prehospital medical evacuation. It requires specifically trained medical teams because the difficulties are marine, aerial, and medically related. The French Navy provides medical evacuations by helicopter on the Atlantic coast, up to 320 km offshore and under all weather conditions. The epidemiology of acute chest pain in the high seas has been poorly described. Therefore, in this retrospective study, we aimed to assess the prevalence and constraints found in the management of these emergencies. From January 1, 2000, to April 30, 2009, 286 medical evacuations by helicopter were performed, 132 of which were due to traumatological emergencies, and 154 to medical emergencies. Acute chest pain, with 36 missions, was the leading cause of medical evacuation. All evacuated patients were men who were either professional sailors or ferry passengers. The median age was 48 years (range, 26-79). The most common prehospital diagnosis was coronary chest pain in 23 patients (64%), including 11 patients with acute coronary syndrome with ST-segment elevation. Thirty-two patients were airlifted by helicopter. All patients benefited from monitoring, electrocardiogram, peripheral venous catheter, and medical management as soon as the technical conditions allowed it.

[Acute heart disease in search and rescue helicopter missions, from French Navy. A retrospective study from 2000 to 2007]

BACKGROUND

Search and rescue helicopters from the French navy conduct ambulance and search and rescue missions near the western coast of the French Britain. The team on board includes military doctor and paramedic. Operations in this area are challenging due to long distances and severe weather conditions.

METHODS

We studied retrospectively 205 search and rescue missions from 2000 to 2007 with special emphasis on acute heart disease and operative conditions.

RESULTS

12.2% of the missions (25/205) concern acute heart disease dominated by myocardial infarction elevation myocardial infarction. All of the patients are male. Most of them are seafarers and the others come from ferries with a median age of 53.4 years. Sixty-two percent of the missions were carried in darkness. The median range is about 80 nautical miles. Two patients died during search and rescue missions. All patient are hospitalized.

CONCLUSION

Ambulance and search and rescue mission near the western coasting of the French Britain are a challenge. Using a heavy helicopter from French Navy was the best way to carry medical treatment to seafarers and passengers of ferries suffering from acute heart disease.

[Recurrent transient ischemic stroke in a young patient with papillary fibroelastoma of the mitral valve and hyperhomocysteinemia. A case report]

We describe a case of a young patient admitted for recurrent ischemic stroke caused by a papillary fibroelastoma of the mitral valve and a hyperhomocysteinemia. A papillary fibroelastoma is a benign cardiac tumor which can be associated with serious embolic complications. A moderate plasma level of hyperhomocysteinemia is considered as a risk factor of ischemic stroke. The authors suggest that this association increases the risk of ischemic stroke in their patient. The tumor was surgically removed to avoid new embolic events associated with a vitamin B supplementation. After surgery and acid folic supplementation, no recurrence was observed.

Cardiovascular disease in patients with spondyloarthropathies

Spondyloarthropathies are associated with a greater cardiovascular risk than expected based on the cardiac lesions known to occur in these diseases. The prevalence of several conventional risk factors is high in spondyloarthropathy patients, and chronic inflammation also contributes to premature plaque formation. In addition, susceptibility genes for spondyloarthropathies may be associated with an increased risk of cardiovascular disease. Finally, several drugs used to treat spondyloarthropathies may contribute to the occurrence of cardiovascular events. A careful evaluation of the cardiovascular risk profile is a key component of the management of patients with spondyloarthropathies.

Accuracy of 16-detector multislice spiral computed tomography in the initial evaluation of dilated cardiomyopathy

BACKGROUND

Multislice Computed Tomography (MSCT) recently proved its accuracy in the detection of coronary artery disease (CAD). It can also give information about left ventricular function and venous network anatomy. We here sought to validate a MSCT-based strategy in the initial evaluation of patients with dilated cardiomyopathy (DCM).

METHODS

36 patients with DCM underwent cardiac MSCT before conventional coronary angiography with ventriculography. We analysed arterial calcium score (Agatston score equivalent: ASE), coronary stenosis, left ventricular parameters and venous network.

RESULTS

The sensitivity of a MSCT-based strategy in detecting significant CAD was 100% and the specificity 80%. The positive and negative predictive values were respectively 67% and 100%. For ASE <1.000 (75% of patients), MSCT detected all non-CAD patients without one (motion artifacts), enabling conventional angiography to be avoided in 21/27 patients (77.7%). For ASE > or =1000, MSCT enabled conventional angiography to be avoided in only 2/9 patients (22.2%). The ventricle was assessable in 83.4% (30 patients) on MSCT. Correlation coefficient Rs with ventriculography were 0.78 (p<0.0001), 0.77 (p<0.0001) and 0.82 (p<0.0001) respectively for end-diastolic volume, end-systolic volume and EF. The venous network was assessable in all patients both on MSCT and angiography.

CONCLUSION

In patients undergoing an initial evaluation of DCM, MSCT appears to be an effective alternative to conventional angiography. The following attitude may be proposed: when ASE >1.000, conventional coronary angiography is mandatory due to MSCT's poor interest in such cases; when ASE <1.000, a contrast-enhanced MSCT may, when normal, replace coronary angiography.

Multi-slice computer tomography of left ventricular function with automated analysis software in comparison with conventional ventriculography

PURPOSE

To evaluate the accuracy of left ventricular volumetric and functional parameters from multi-slice computed tomography using automated analysis software, and to correlate results with those of invasive left ventriculography.

MATERIALS AND METHODS

In 145 consecutive patients (mean age, 61 years+/-12) known or suspected to have coronary artery disease, a 16-channel multi-slice computed tomography (Philips Mx8000 IDT 16) was performed using a standard technique. Using short-axis secondary multi-slice computed tomography reformations, we determined end-diastolic and end-systolic left ventricular volumes and ejection fraction with a commercially available analysis software capable of automated contour detection. Conventional left ventriculography was performed according to standard techniques within the following 24 h. Bland-Altman analysis was performed to calculate the limits of agreement and systematic errors between multi-slice computed tomography and conventional left ventriculography.

RESULTS

As determined by computer tomography, mean end-systolic (53+/-29 mL) left ventricular volumes had an acceptable correlation with conventional ventriculography (67+/-50 mL; r=0.74; p<0.001) and mean end-diastolic (119+/-33 mL) left ventricular volumes a poor correlation with conventional ventriculography measurements (154+/-69 mL; r=0.41). Left ventricular ejection fraction (57%+/-14 versus 55%+/-14 for conventional ventriculography; r=0.79) showed a very good correlation (p<0.001). Bland-Altman analysis showed acceptable limits of agreement (+/-9.2% for ejection fraction) without systematic errors.

CONCLUSION

The use of a multi-slice computed tomography with an automatic calculation software has a good correlation with conventional ventriculography findings and could accurately assess left ventricular function, but should not be used for ventricular volumes, because of biased estimations.

Interférence analytique dans le dosage semi-quantitatif de la procalcitonine (PCT-Q® Brahms®)

Procalcitonin (PCT) is a biological marker of infection. We present the cas of a patient who has presented a high concentration of PCT with PCT-Q test (Brahms). At the same time, the concentration of CRP is remained low, which is no physiological. Then, PCT concentration has been determinated with an automatic system (Kryptor-Brahms) and finded at low than 0.5 microg/l. Brahms company has searched an analytical interference: human anti-mouse antibodies (HAMA) were positive. If PCT concentration stay a marker of infection for the most part, this case show that biologists have to keep in mind that immunological assays remain submitted to interferences.

Syndrome de Sharp et bloc de conduction auriculo-ventriculaire aigu du second degré. À propos d'une observation

INTRODUCTION

Mixed connective tissue disease (MCTD) is characterized by overlapping features of progressive systemic sclerosis, dermatomyositis and systemic lupus erythematosus, and by high rate of antibodies to an extractable nuclear antigen ribonucleoprotein. Cardiac manifestations in MTCD are rare.

EXEGESIS

A 58 years old man was admitted for mild fever, a impairment of the general status, muscular pain and a Raynaud's phenomenon. Biologic abnormalities were an inflammatory syndrome, elevated serum CPK and high rate anti-RNP antibodies. Diagnosis of mixed connective tissue disease was made. Shortly after, a Wenckebach atrioventricular block occurred. Systemic corticosteroids were efficient.

CONCLUSION

Heart blocks are rarely described in MCTD. Three cases have been reported. It's a systemic complication resulting of an inflammatory process often responsive to steroids.