The aim of this study was to evaluate prospectively the clinical impact of routine transmission of CYP2C19 genotype in the management of acute ST-segment elevation myocardial infarction with primary ...percutaneous coronary intervention.
Response to clopidogrel differs widely among patients, notably because of CYP2C19 genetic polymorphisms.
CYP2C19 genotype (6 alleles) was determined centrally and communicated within 4.1 ± 1.9 days of primary percutaneous coronary intervention in 1,445 patients with ST-segment elevation myocardial infarction recruited at 57 centers in France. CYP2C19 metabolic status was predicted from genotype and served to adjust thienopyridine treatment. The primary endpoint was differences in 12-month outcomes (death, myocardial infarction, and stent thrombosis) between patients with the wild-type genotype or gain-of-function allele (class 1, n = 1,118) and those with loss-of-function (LOF) alleles (class 2, n = 272) who received optimized thienopyridine treatment.
Detection of LOF alleles resulted in adjustment of P2Y
inhibition in 85% of patients, with significantly higher use of prasugrel or double-dose clopidogrel. The primary endpoint did not differ between class 1 and class 2 patients (3.31% vs. 3.04%, respectively; p = 0.82). In contrast, carriers of LOF alleles without treatment adjustment had significantly worse outcomes (15.6%; p < 0.05). Bleeding rates were not different between groups.
In a real-world setting, a complete CYPC2C19 genotype can be mostly determined in <7 days using analysis of saliva deoxyribonucleic acid collected during the in-hospital phase among patients with ST-segment elevation myocardial infarction treated with primary percutaneous coronary intervention. Genotype information led to stronger platelet inhibition treatment in the vast majority of LOF allele carriers and to similar clinical outcomes as in patients carrying the wild-type genotype or gain-of-function allele. (Genotyping Infarct Patients to Adjust and Normalize Thienopyridine Treatment GIANT; NCT01134380).
Abstract Background To gain more insight into the involvement of inflammatory response and neurohumoral activation in Takotsubo cardiomyopathy (TTC), we investigated C-reactive protein (CRP), ...leukocytes, plasma catecholamines levels, iodine 123 meta-iodobenzylguanidine (123 I-mIBG) myocardial uptake, myocardial perfusion (thallium 201 201 Tl or technetium Tc 99m-tetrofosmin myocardial single photon emission computed tomography SPECT), and metabolism (fluorine 18-fluorodeoxyglucose positron emission tomography). Methods and Results Inflammatory status and brain natriuretic peptide (BNP) levels in 17 patients with TTC were compared with 14 age-matched patients. In TTC, elevated levels of CRP were evidenced on admission, reaching a peak in the following days ( P < .01). CRP levels were correlated to baseline left ventricular ejection fraction (LVEF) and BNP levels ( P < .05). Leukocytes were correlated to BNP and noradrenaline levels. Myocardial123 I-mIBG SPECT showed a reduced activity in the midventricle and apex corresponding to 35% ± 23% of the total myocardial mass, partially reversible at follow-up. An identical pattern was retrieved when assessing myocardial glucose metabolism. At rest, no relevant abnormalities of myocardial perfusion could be evidenced at the subacute phase. Conclusion Inflammatory status in TTC was related to LVEF impairment and to the extent of neurohormonal activation. The hypothesis of a catecholamine-induced myocardial “stunning” is emphasized by the evidence of a reduced123 I-mIBG myocardial activity, impairment of myocardial glucose metabolism, and wall motion kinetic after the same temporospatial distribution.
L'accès radial est devenu la voie d'abord privilégiée des Cardiologues interventionnels et des patients. L'occlusion de l'artère radiale conventionnelle peut limiter son utilisation à d'autres fins ...(pontages, fistules artério-veineuses, répétition des ponctions). L'abord radial distal constitue une alternative à la radiale conventionnelle, cependant son adoption reste limitée.
Évaluer la faisabilité et la sécurité à court terme de l'abord radial distal dans notre pratique quotidienne.
Nous avions mené une étude transversale, monocentrique et descriptive du 1er Mars au 30 Avril 2023.
La population d’étude était constituée des patients hospitalisés, devant bénéficier d'une intervention coronaire percutanée. Le critère d'inclusion était une bonne perception d'un pouls radial proximal et distal. Les critères d'exclusions étaient un syndrome coronaire aigu avec sus décalage du segment ST, une instabilité hémodynamique et toute contre-indication ou accès impossible à la voie radiale.
Cent neuf patients ont été inclus. L’âge moyen était de 67,52 ± 13,58 ans. On retrouvait une prédominance masculine à 84,4%. Un surpoids ou une obésité était le facteur de risque le plus fréquemment retrouvé, (74,3%) suivi de l'hypertension artérielle (62,4%) et du tabagisme (48,6%).
Les indications étaient dominées par les syndromes coronaires chroniques (42,2%) suivis des dépistages de coronaropathie (31,2%). Cinq patients étaient admis pour un infarctus sans sus décalage du segment ST.
Un abord radial distal droit était noté dans la majorité des cas (91,7%). Soixante-sept soit 61,5% des procédures étaient des coronarographies seules, 32,1% des angioplasties et 6,4% des coronarographies avec FFR seule. Une aiguille était utilisée dans 90,8% des cas et un cathlon chez le reste des patients. Un guidage échographique était utilisé chez 26 patients. Le taux de succès était de 94,5% et on notait 8 cross-over (7,3%) dont 6 liés à un échec de ponction et 2 à la présence d'une récurrente. La sonde Tiger 4 utilisée en première intention dans nos procédures diagnostiques a permis d'achever 58,5% des coronarographies; l'association à une autre sonde était nécessaire dans 16% des cas et pour le reste des patients d'autres sondes ont été utilisées.
Un taux de complication de 4,58% était retrouvé, essentiellement constitué d'un hématome mineur chez 2 patients (1,83%) et d'une abolition du pouls chez 3 patients (2,75%). Aucune complication majeure n'a été répertoriée. Un spasme radial considéré comme événement indésirable était retrouvé dans 6,4% des cas (fig. 1 à 4).
L'accès radial distal est une voie d'abord sûre, au taux de succès élevé, permettant d'achever un nombre important de procédures de coronarographies et/ou d'angioplastie et de préserver un éventuel abord radial conventionnel ultérieur. Elle reste actuellement peu répandue et son utilisation nécessite une courbe d'apprentissage.
Pas de conflit d'intérêt
Resuscitation of large burn injuries must quickly restore and maintain cardiovascular function and fluid balance while minimizing secondary edema-related damage. We tested the hypothesis that two ...4-mL x kg(-1) doses of hypertonic saline dextran (HSD; 7.5% NaCl/6% dextran-70) can produce prolonged reduction in fluid requirements after burn injury.
Prospective, pseudo randomized, double-blind study.
Animal research laboratory.
Female adult Merino sheep (n = 12).
Sheep were given a 40% total body surface area full-thickness flame burn under halothane anesthesia. One hour after the burn, the conscious animals received an initial dose of 4 mL x kg(-1) HSD (n = 6) or normal saline (NS; NaCl 0.9%) (n = 6) intravenously during 30 mins. This was followed by lactated Ringer's solution, infused to a target urine output of 1 mL x kg(-1) x hr(-1) throughout the 24-hr study. A second 4-mL x kg(-1) dose of HSD or NS was started at 12 hrs, and infused during 5 hrs.
Hourly urine output measurements were used to guide the infusion rate of the lactated Ringer's. The initial infusion of HSD 1 hr after the burn injury promptly restored cardiac index, promoted diuresis, and reduced fluid requirements compared with the NS controls (73% reduction for HSD relative to NS at 8 hrs). Subsequent rebound fluid accumulation resulted in similar net fluid balances in both groups within 12 hrs after the burn. The second dose of HSD, given at 12 hrs, was without effect on hemodynamics and fluid balance.
We conclude a considerable initial, but not sustained fluid-sparing effect of early HSD, and no effect of a late, slowly infused HSD dose in this two-dose regimen.
Supraceliac aortic occlusion (AO) has been recommended to avoid hypotension during hepatic vascular exclusion (HVE). We hypothesized that AO may negatively affect splanchnic perfusion during HVE.
...Twenty-six dogs (16 ± 0.3 kg) were randomly assigned to HVE (n = 13) or HVE+AO (n = 13), during 30 minutes followed by a 60-minute reperfusion period. Cardiac output (CO), mean arterial pressure (MAP), superior mesenteric artery blood flow (SMABF, ultrasonic flowprobe), gastric mucosal PCO
2 (gas tonometry) and PCO
2-gap were evaluated.
HVE alone induced decreases in MAP from 115 ± 5.1 to 26 ± 1 mm Hg, in CO from 2.0 ± 0.1 to 0.4 ± 0.1 L/min and SMABF from 398 ± 42 to 16 ± 7.6 mL/min, while PCO
2 gap increased from 4 ± 3.7 to 52 ± 5.4 mm Hg. Supraceliac aortic occlusion only avoided severe hypotension. During reperfusion MAP, CO, and SMABF were partially restored, while PCO
2 gap showed no improvements in either group.
HVE promotes major systemic and splanchnic perfusional derangement. Concomitant AO may avoid HVE-induced hypotension without producing further deleterious effects.
X-ray doses (delivered) to the patients during coronary angiography (CA) and percutaneous coronary intervention (PCI) show ability of one certain deterious effects and can be sometimes at very high ...level. According to the European directives, all the equipments allowing to make diagnostic and interventional procedure integrate a unit of measure of the Dose Area Product. This measure is associated in a linear way with the effective dose and allows to measure the stochastic risk, the indicator also of good practices. Stemming from general vascular rotational acquisition technology, the cardiac rotational angiography is potentially beneficial for the patients and the operators concerning the exposure in ionizing radiations. The purpose of this study is to measure retrospectively the various dominating indicators in the irradiation of the patients on a series of case realized from January, 2009 till May, 2009 further to the implementation of this technique of acquisition. The dose area product, the duration of fluoroscopy as well as the number of acquired images were measured after coronary angiogram at 250 consecutive patients between January, 2009 and May, 2009. The procedures were realized by four operators, using the femoral access. The dose area product, the durations of fluoroscopy as well as the number of images has been respectively of 39,3 Gy cm(2) 4,7-210,65 Gy cm(2), 8,4 minutes 0,8-38 minutes and 575 frames 175-1427 frames in standard coronary angiogram; 33,64 Gy cm(2) 4,95-85,6 Gy cm(2), 2,8 minutes 1,1-26 minutes, 503 frames 314-836 frames in single rotational coronary angiogram; 24,26 Gy cm(2) 5,74-51,1 Gy cm(2), 3,9 minutes 1,3-14 minutes, 272 frames 127-429 frames in double rotational coronary angiogram. In conclusion, the exposure of the patient to the X-rays, the practitioners and paramedical in interventional cardiology depends on the operator, on the fluoroscopy time and on the number of acquired images. The double rotational angiography is one of the solution to achieve these objectives.
La survenue d’une thrombose intraventriculaire est un événement grave, compliquant le plus souvent un infarctus étendu. Elle nécessite une prise en charge médicale adaptée, basée sur les ...anticoagulants oraux habituels, sans lesquels le risque embolique est élevé. Le diagnostic est le plus souvent réalisé par l’échocardiographie transthoracique mais avec une sensibilité et une spécificité insuffisantes. La place de l’IRM cardiaque dans ce contexte reste à explorer.
Nous avons réalisé un registre rétrospectif de toutes les IRM réalisées dans notre service depuis 2003, pour bilan d’une masse intracardiaque ou d’un accident vasculaire cérébral. Le but était de comparer les résultats à ceux de l’échocardiographie et de la ventriculographie de contraste et d’évaluer les performances de ces différentes modalités d’imagerie.
Notre série comprend 26 cas de thrombus intraventriculaire, confirmés par l’IRM cardiaque. Nos résultats confirment le manque de sensibilité de l’échocardiographie et de la ventriculographie. On retrouve un coefficient de corrélation Kappa de l’échographie et de la ventriculographie, vis-à-vis de l’IRM, très faible, respectivement de –0,08 et 0,16.
Les performances de l’échocardiographie et de la ventriculographie de contraste pour rechercher une thrombose intraventriculaire semblent limitées. La réalisation d’une IRM cardiaque complémentaire doit etre préconisée le plus souvent possible en cas de doute diagnostique ou de situation à risque.
Intraventricular thrombosis is a serious event, generally complicating a wide myocardial infarction. It requires an adapted therapy, based on the oral anticoagulants. The diagnosis is generally carried out by trans-thoracic echocardiography but with an insufficient sensitivity and a specificity. In this context, the place of cardiac MRI remains to be explored.
We carried out a retrospective registry of all cardiac MRI done in our hospital since 2003, for assessment of an intracardiac mass or an cerebral stroke. The aim was to compare the results of cardiac MRI with those of echocardiography and contrast ventriculography.
Our registry includes 26 cases of intraventricular thrombi, confirmed by cardiac MRI. Our results confirm the lack of sensitivity of echocardiography and the ventriculography. The Kappa correlation coefficient of echocardiography and ventriculography, with respect to the MRI, are very weak, respectively of −0.08 and 0.16.
The values of echocardiography and contrast ventriculography seem limited. The realization of a complementary cardiac MRI must be recommended as often as possible in case of doubt or high risk disease.
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