Recent studies have challenged systematic pretreatment with a P2Y12 inhibitor before percutaneous coronary intervention (PCI) in elective and non-ST-segment elevation myocardial infarction (NSTEMI) patients. The aim of this study was to assess outcomes after performing PCI immediately after coronary angiography with an exclusive ‘on-the-table’ P2Y12 inhibitor loading dose, by evaluating ischaemic and bleeding complications in unselected patients. Consecutive patients admitted for elective PCI or NSTEMI were included in this bicentric, prospective observational study, and received a P2Y12 inhibitor after coronary angiography when PCI was decided. The primary composite endpoint was first occurrence of cardiovascular death, myocardial infarction, stroke, urgent revascularisation or use of bailout glycoprotein IIb/IIIa inhibitors at 30 days after PCI. Stent thrombosis and bleedings (Bleeding Academic Research Consortium [BARC]) criteria were evaluated. Among 299 included patients, 188 were admitted for elective PCI and 111 for NSTEMI. The incidence of the primary endpoint was 8.5% (95% CI 5.7 to 12.4). No definite stent thrombosis occurred. Three independent predictive factors were associated with the primary endpoint: NSTEMI setting (OR 5.61 (95% CI 1.75 to 17.98), thrombotic coronary lesion (OR 4.26 (95% CI 1.45 to 12.54) and longer procedure duration (OR 1.06 (95% CI 1.03 to 1.09). Clinically relevant bleedings (BARC type 2, 3 or 5) occurred in 5.4% of patients. In an unselected population admitted for elective PCI or NSTEMI in real-life practice, administration of a P2Y12 inhibitor only after coronary angiography is associated with a low rate of ischaemic and bleeding events at 30 days.

OBJECTIVESRecent studies have challenged systematic pretreatment with a P2Y12 inhibitor before percutaneous coronary intervention (PCI) in elective and non-ST segment elevation myocardial infarction (NSTEMI) patients. The aim of this study was to assess outcomes after performing PCI immediately after coronary angiography with an exclusive "on-the-table" P2Y12 inhibitor loading dose, by evaluating ischemic and bleeding complications in unselected patients.METHODSConsecutive patients admitted for elective PCI or NSTEMI were included in this two-center, prospective, observational study, and received a P2Y12 inhibitor after coronary angiography when PCI was decided. The primary composite endpoint was first occurrence of cardiovascular death, myocardial infarction, stroke, urgent revascularization, or use of bail-out glycoprotein IIb/IIIa inhibitors at 30 days after PCI. Stent thrombosis and bleeding criteria (Bleeding Academic Research Consortium [BARC]) were evaluated.RESULTSAmong 299 included patients, a total of 188 were admitted for elective PCI and 111 for NSTEMI. The incidence of the primary endpoint was 8.5% (95% confidence interval [CI], 5.7-12.4). No definite stent thrombosis occurred. Three independent predictive factors were associated with the primary endpoint: NSTEMI setting (odds ratio [OR], 5.61; 95% CI, 1.75-17.98), thrombotic coronary lesion (OR, 4.26; 95% CI, 1.45-12.54), and longer procedure duration (OR, 1.06; 95% CI, 1.03-1.09). Clinically relevant bleedings (BARC 2, 3, or 5) occurred in 5.4% of patients.CONCLUSIONSIn an unselected population admitted for elective PCI or NSTEMI in real-world clinical practice, administration of a P2Y12 inhibitor only after coronary angiography is associated with a low rate of ischemic and bleeding events at 30 days.

Background. Little information is available on the long-term incidence of bleeding events after ST-segment elevation myocardial infarction (STEMI) with the current antithrombotic strategy.Aims. To evaluate the effect of bleedings for up to 12 months on clinical events and therapeutic compliance in unselected STEMI patients treated with prasugrel or clopidogrel.Methods. Patients were treated with clopidogrel or prasugrel according to guidelines. The primary endpoint was first occurrence of a bleeding event from hospital discharge to 12 months, assessed by the Bleeding Academic Research Consortium (BARC) classification using a dedicated questionnaire. Topography of bleedings, causes of premature cessation and ischaemic events were compared between clopidogrel- and prasugrel-treated patients.Results. A total of 390 patients were enrolled (211 in the prasugrel group, 179 in the clopidogrel group). Elderly, female and low-body weight patients were more likely to receive clopidogrel. At 12 months, the incidence of major bleedings (BARC 3) was lower with prasugrel (1% vs 6%; P=0.02), mainly due to fewer transfusions. Elderly age was a risk factor for severe bleeding. Premature treatment cessation was related to ischaemic complications (P=0.03), and occurred more frequently with prasugrel (P=0.001). One-year mortality was very low (1.9 per 100 person-years, 95% confidence interval 0.9-4.0), and was higher in the clopidogrel group (P=0.03).Conclusions. In this unselected STEMI population, the rate of major bleedings with prasugrel at 12 months was low, but nuisance bleedings were frequent and led to more premature cessations than with clopidogrel. Prevention of bleeding complications, even minor, is necessary to prevent disruption of antithrombotic medication. (C) 2016 Elsevier Masson SAS. All rights reserved.

The aim of this study was to evaluate one-year incidence of bleeding events and their impact on compliance in patients admitted for ST Elevation Myocardial Infarction (STEMI) and treated by prasugrel or clopidogrel in « real-world ». Patients admitted for a STEMI were treated by either clopidogrel or prasugrel according to the physician with respect of guidelines. The primary endpoint was the first occurrence of bleeding events within 12 months assessed by the Bleeding Academic Research Consortium (BARC) classification using a dedicated questionnaire focused on bleeding events. Topography bleedings, causes of premature cessation and ischemic events were also compared. 390 patients were enrolled, 211 in prasugrel group and 179 in clopidogrel group. Patients in the prasugrel group were younger, with higher body weight and were more frequently men. At 12 months, a bleeding complication occurred in 40% of patients regardless of its severity or treatment prescribed. Major bleedings (BARC 3) were significantly lower with prasugrel than clopidogrel (1% versus 6%, p=0.001). Minimal bleedings (BARC 1) were more frequent in clopidogrel group than prasugrel group (respectively 27% and 18%; p=0.05). However BARC 2 bleedings occurred more often in prasugrel group (14% versus 6%, p=0.01) (figure). Subcutaneous and gastrointestinal haemorraghes were the most frequent. Over one-year, the rate of cessation was 18% in the prasugrel group and only 10% in the clopidogrel group (p=0.04). Respectively for prasugrel and clopidogrel, rates of recommend discontinuation were 10% and 4% (p=0.02) and of disruption were 8% and 5% (p=0.3). Despite more frequent discontinuation, mortality remains very low in the prasugrel group (0.5% versus 7%, p=0.0003). In real-world, in a low bleeding risk population, the rate of major bleedings with prasugrel at 12 months was low but nuisance bleedings were frequent with significant impact on premature cessation Download : Download full-size imageAbstract 0098 – Figure: 12 months bleedings classification Abstract 0098 – Figure: 12 months bleedings classification

A 50-year-old woman was admitted for an inferior ST-segment elevation myocardial infarction; immediate coronary angiogram revealed a subocclusive stenosis of the right coronary artery. After optimal antithrombotic treatment, the type of stent could be discussed. The latest generation of drug-eluting stents showed excellent efficacy and safety in the long-term but has limitations such as potential chronic inflammation of the arterial wall and no recovery of vasoactive function. Bioresorbable vascular scaffolds, with complete resorption within several months, may reduce these limitations. Implantation of bioresorbable scaffold in the context of myocardial infarction may be interesting. However, very few studies are currently available in this setting. Preliminary results and perspectives are presented in this review.

Premature discontinuation of antiplatelet therapy is a major risk factor of stent thrombosis after drug-eluting stent placement leading to an increased risk of death. We sought to determine by a simple questionnaire the prevalence of patients at risk for premature discontinuation of oral antiplatelet therapy in elective percutaneous coronary intervention (PCI). Patients scheduled for elective PCI underwent a routine interview (RI) and a specific questionnaire (SQ) by two independent physicians the day before the intervention. The SQ was designed to identify bleeding disorders, suspected cancer, planned invasive procedures and self evaluation of compliance. The final decision of drug eluting stent (DES) implantation was made by a third independent physician who performed the planned PCI and who had full access to the patient record. At least one contraindication to DES implantation was found in one third of the study population (82/302, 27%) after the RI. All these patients were also identified by the SQ. At total of 31 additional patients were identified by the SQ as non eligible for DES implantation. Active bleeding (n = 14) and scheduled biopsies (n = 4) were the two main contraindications to DES implantation isolated by the SQ. Patients characteristics and angiographic findings identified 59.9% patients (n = 181/302) eligible for a DES implantation. Finally the physician performing the PCI excluded 66.3% of the patients (n = 79/302) who could receive a DES and implanted a bare metal stent (BMS) instead. This decision was based on the findings of the dedicated questionnaire on top of the interview in 30 patients (38%) and in 49 patients (62%) for other reasons. In elective PCI, a simple questionnaire used before DES implantation can improve identification of patients at high risk for premature discontinuation of antiplatelet therapy.

We present the case of a 67‐year‐old woman with cardiomyopathy induced by inappropriate sinus tachycardia (IST) and a particularly high average heart rate. The patient was resistant and/or intolerant to treatment with conventional rate‐slowing medications. We used ivabradine—a specific sinus node I f current inhibitor—and successfully lowered the heart rate (33 beats per minute mean heart rate decrease). Symptoms, systolic function, and heart rate variability parameters recovered dramatically. No side effect was noted. We suggest that ivabradine—evaluated in trials to treat stable angina—should be considered as a second‐line treatment in patients with very symptomatic and refractory IST.

No study has reported the long term effects of cardiac rehabilitation, concerning the duration of beneficial effects of training program. The present study analyzed the influence of training session frequency on long-term beneficial effects in patients with coronary artery disease (CAD) undergoing phase 2 cardiac rehabilitation. Four patients with CAD completed 20 training sessions. Two patients were assigned to low training frequency (LTF) and two to high training frequency (HTF): three and five sessions per week−1, respectively. The method was based on the systems model of training and required training quantification and the assessment of real exercise tolerance. Convolution of training quantity with real exercise tolerance provided the model exercise tolerance for every patient. The model parameters, the magnitude factor (k), and the time constant of decay (τ), were fitted from real and model exercise tolerances by the least squares method. LTF and HTF resulted in similar increases in exercise tolerance (12–14%). A model with one-component (fitness) allowed fitting exercise tolerance in all patients with r 2=0.77, 0.79, 0.84, and 0.91, respectively (p<0.05). The addition of a second component did not improve the fit in any patient (p>0.05). The k value was about twice as high with LTF (0.13 and 0.16 AU) than with HTF (0.05 AU for the two patients), whereas the τ value was about twice as low with LTF (37 and 41 days) than with HTF (72 and 89 days). The long term beneficial effects estimated by 4τ, were twice as long with HTF (288 and 356 days) than with LTF (148 and 164 days). We concluded that exercise tolerance was similarly increased with HTF and LTF but HTF training induced beneficial effects which were sustained twice as long.

Pulse wave velocity measurement is used as an index of arterial stiffness. The purpose was to evaluate the reproducibility of pulse wave velocity measurement at rest, during exercise and recovery from exercise, using an automated device. Twelve healthy young adults (mean age 22.0 +/- 3.1 yrs) underwent an upright submaximal cycle test on two separate occasions, one week apart. Pulse wave velocity, systolic and diastolic blood pressures and heart rate were assessed at rest, during the last 2 min of exercise and 10 min later. Pulse wave velocity was measured on the upper limb and the forearm by the cross-correlation function of photoplethysmography and Doppler signals. Brachial artery pulse wave velocity was calculated from upper limb and forearm pulse wave velocities. No significant difference was found on duplicate measurements of heart rate, systolic and diastolic blood pressures at rest, during exercise and recovery, showing that pulse wave velocity was measured under similar conditions. Coefficient of variation for upper limb and forearm pulse wave velocities ranged from 2.9 to 5.9% at rest and during recovery, and were respectively 2.9% and 8.3% during exercise. However, coefficient of variation for brachial pulse wave velocity was 7.7 and 10.3% at rest, 15.7% during exercise, and 5.8% during recovery. During exercise, pulse wave velocity measurements were satisfying, but indirect assessment of brachial artery pulse wave velocity showed poor reproducibility. Thus, upper limb and forearm pulse wave velocities may be used during exercise to assess the effect of training or drugs on arterial wall mechanical properties.

BACKGROUND:The aim of this study was to apply a systems model of training for athletes in patients with coronary artery disease (CAD) undergoing phase 2 cardiac rehabilitation.METHODS:Data from six patients with CAD undergoing 20 conventional training sessions were used to test this model. The method required daily training quantification using heart rate, and regular assessment of real exercise tolerance using a constant-duration test. Convolution of training quantity with real exercise tolerance was provided for every patient model exercise tolerance, by minimizing the residual sum of squares.RESULTS:The results showed that application of the systems model of training to the six patients resulted in a strong fit between real and model exercise tolerances: r(2) = 0.77, 0.79, 0.83, 0.84, 0.85 and 0.92, respectively (P < 0.05).DISCUSSION:Moreover, the systems model admitted for all patients corresponded to one first-order transfer function, which was fitness. This result was in contrast with the systems models reported in athletes and in a patient with CAD undergoing phase 3 cardiac rehabilitation which were found to include two first-order transfer functions: fitness and fatigue, simultaneously.CONCLUSION:The systems model of training of patients with CAD undergoing phase 2 suggested two practical consequences: first, the improvement of exercise tolerance is directly related to training, and consequently second, patients who enter immediately phase 3 training may prevent a decrease in their exercise tolerance.

A patient with coronary artery disease performed a 14-week cardiac rehabilitation program. Endurance exercise tolerance was assessed using a constant-duration exercise test performed before, immediately after and one month after the program. The results showed that endurance exercise tolerance achieved a higher value at one month post-training. We concluded that the usual pre- versus post-test comparison underestimated the beneficial effects of training program. This must be taken into account for long term planning of phase 3 cardiac rehabilitation.

PURPOSE:The aim of the present study was to apply a systems model of training for athletes to a patient with coronary artery disease (CAD) undergoing phase 3 rehabilitation. METHODS:A patient with CAD underwent 14 wk of training during which exercise was quantified using intensity and duration. Real exercise tolerance was assessed twice a week during this period using a constant-load test. The model exercise tolerance was obtained by convolving the quantified training to real exercise tolerance. The model parameters were obtained by fitting the real exercise tolerance to model exercise tolerance by the least square method. These parameters were then used to calculate the time needed after a training impulse to reach maximal tolerance (tg) and then to return to the pretraining level of tolerance (ti). RESULTS:The results showed that: 1) the fit between real and model exercise tolerances was significant (r = 0.73, P < 0.05), and 2) tg and ti were predicted 17 and 120 d posttraining, respectively. CONCLUSIONS:The application of a systems model of training for athletes to a patient with CAD was successful. We were able to predict the maximal exercise tolerance and the duration of increased tolerance subsequent to the training period.

Aims. - To study T-wave amplitude changes during exercise and recovery in trained athletes.Methods and results. - Thirty two athletes of both sexes underwent an incremental cycle test. Cardiac electric activity (ECG) was recorded every minute during exercise and the following five minutes of recovery. T-wave amplitude was manually measured on V5 ECG complex enlarged 4-fold. The statistical analysis was done using two factor's Anova. The results showed that T-wave amplitude 1) increased significantly during the three first minutes of the recovery, 2) was not linked to T-wave decrease or increase during previous exercise, and 3) was significantly lower in females than in males. Pathophysiological mechanisms of this ECG repolarisation in athletes during recovery following exercise remains unclear. (C) 2003 Editions scientifiques et medicales Elsevier SAS. All rights reserved.

OBJECTIFS : Comparer l’efficacité du réentraînement à l’effort chez le coronarien en fonction de la fréquence cardiaque (Fc) d’entraînement déterminée lors de l’épreuve d’effort selon deux modalités : FEK selon la formule de Karvonen = 70 % (Fc max - Fc repos) + Fc repos, ou FES = fréquence cardiaque mesurée au seuil ventilatoire (SV).

PURPOSE To compare the efficiency of two programs of exercise-based rehabilitation that are different for heart rate (HR) training in patients with coronary artery disease: heart rate (HR) according to Karvonen formula (HR training =70% (max HR -rest HR) +rest HR) or HR recorded at the gas exchange ventilatory threshold (VT). TYPE: Controlled randomised clinical trial. SETTING Cardiovascular rehabilitation unit. METHOD Twenty-four male patients (54 +/-9.5 years old) with coronary artery disease were allocated at random to one of the two groups: KHR group (n =13) according to Karvonen formula (n =11), and VTHR group according to VT determined by exertion test (n =13). The exercised-based program was similar for all the patients, differing only in HR training (five daily sessions a week for four weeks). Assessment tests were performed at D1 and D28 and included: - an exercise test with measure of HR and double product (HR x blood pressure) at rest, submaximal and maximal intensity, with measure of oxygen consumption and gas exchanges at rest and at maximum exercise; - specific functional tests based on daily life activities; - dyspnea assessment at maximal intensity; - quality of life measurement by SF36. It was taken notice of the drugs taken by the patients, specially betablockers. RESULTS At inclusion, the two groups were not different for parametric (age, body mass index) and non parametric values (medical or surgical treatment, comorbidity). Even though HR training was significantly different (p <10(-6)), at the end of the program there was a significant increase of power and oxygen consumption at VT (+42.6%, p <10(-6); +18.6%, p <10(-5)) and at maximal intensity (+18.7 %, p <10(-6); 14.2 %, p <10(-5)), but differences between the two groups were not significant; double product was significantly lower at rest (-13.9 %, p <10(-5)) and at submaximal exertion (-10.6 %, p < 10(-3)). Yet, the two groups differed in HR, and HR increased in VTHR group and decreased in KHR, the difference being significant at VT (p =0.05), at submaximal (p =0.037) and maximal exercise (p = 0.05). Dyspnea at maximal intensity was higher in VTHR but SF36 values were not different. DISCUSSION AND CONCLUSION These results confirm the efficiency of cardiac training program according to Karvonen formula as to ventilatory threshold. However, there is a negative chronotropic effect of cardiac training according to Karvonen formula with a higher intensity, which corresponds to a less cardiac work for a same activity.

The role of transcranial Doppler ultrasonography (TCD) in individual risk assessment of embolic complications and the development of prevention strategies during coronary angiography remains to be determined. The purpose of this study was to assess the prevalence, time of occurrence and potential significance of microembolic signals (MES) detected with TCD during femoral left heart catheterization. TCD monitoring of the right and left middle cerebral artery was performed in 51 consecutive patients (36 men, 15 women) who were referred for coronary angiography. Percutaneous coronary angioplasty was performed during the same procedure in 16 patients. MES were counted manually during and after (off-line analysis) the procedure. Two patients were excluded from analysis because of the absence of an adequate acoustic temporal window. No neurological event occurred within 24 h in the 49 included patients. MES were detected in all except 2 patients (mean number 17.1 ± 12.8 per patient), mainly during left ventriculography (38%) and contrast media injection into the coronary arteries (55%), suggesting their gaseous origin. There was no statistically significant association between the number of MES and patient age, cardiovascular history and risk factors, or catheterization results. The presence of coronary artery disease was inversely related to the number of MES (15.8 ± 0.3 compared to 21.8 ± 0.2 per patient when a normal angiogram was present; p < 0.05). In conclusion, although asymptomatic microemboli commonly occur during left heart catheterization, the majority of them are probably of gaseous origin, since they occurred predominantly during contrast media injection in this study, and were not related to cardiovascular history or to atheroma risk factors. Because air embolism has been reported to be harmful, attempts to reduce its occurrence during catheter-based procedures could be pertinent.

We reported the case of an acute aortic dissection complicating right guiding catheter manipulation during engagement in the right coronary ostium. Despite absence of hemodynamic deterioration, dissection progressed rapidly from the sinus of Valsalva to the ascending aorta along its entire length. At surgery, performed in emergency, the aorta was not dilated and the aortic wall did not appear pathologic. Therefore conservative surgery was performed, consisting of suture of the aortic tear and incollage of the false lumen, with good immediate and mid-term results.

OBJECTIVES The objective of this study was to determine whether a small-size valve prosthesis contributes to exercise intolerance, as assessed by VO2 measurement during an exhaustive cycle ergometer exercise.BACKGROUNDS The determinants of exercise capacity after mechanical aortic replacement are not well known. The selection of small valve sizes has, however, been described as an independent predictor of exercise intolerance as assessed by exercise duration. Maximal oxygen uptake (VO2, max) is a good index of exercise tolerance.METHODS Fourteen patients were eligible, with a mean age of 62 +/- 6 years. Before surgery, the mean left ventricular ejection fraction (LVEF) was 73 +/- 8%. Two valve types with small diameter (19 to 21 mm) were used: Medtronic Hall and St Jude Medical. A healthy sedentary control group (n = 14) paired for age, weight and size was constituted. After one year of follow-up, cardiorespiratory tests were performed. In addition, the gradients through the prostheses were determined by continuous pulse Doppler at rest and immediately after the cardiorespiratory test.RESULTS The exercise tolerance was not significantly different between the control group and patient group: VO2, peak (21.7 vs. 20.4 ml/kg/min; p = 0.42), workloads (115 vs. 93 W; p = 0.13) and ventilatory parameters were similar. The mean and peak gradients at rest and during exercise were not correlated with VO2 max.CONCLUSIONS Valve replacement by small aortic prosthesis does not seem to be a factor of exercise intolerance as assessed by VO2 max in patients without LVEF dysfunction before surgery. (C) 2000 by the American College of Cardiology.

The characteristics of neurocardiogenic syncope (NCS) in elderly patients remain unclear. We compared the hemodynamic profiles of young and older patients with consecutive and positive head-up tilt tests (HUT). Continuous, noninvasive, and reliable monitoring of arterial pressure (AP) and heart rate (HR) was done throughout 46 consecutive positive HUTs of symptomatic patients. The population (12-82 years old) was divided into two groups: younger patients, Y (n = 25, < or = 65 years), and older patients, O (n = 21). Changes in AP and HR after the first minute of tilting, during the stable orthostatic phase and during syncope were compared. Except for systolic pressure, baseline hemodynamic parameters were similar in Y and O. No difference appeared in the mean time elapsed before syncope (19+/-9 vs 22+/-2 min). Asymptomatic hypotension was observed, only in O, 1 minute after tilting, followed by a progressive fall in the mean AP before syncope (0+/-0.9 vs -1+/-0.7 mmHg/min) without HR increase (0.7+/-1 vs 0+/-0.6 beats/min). This pressure slope was strongly related to age (r = 0.54, P < 0.001). Hemodynamic recording during HUT identifies a dysautonomic pattern in elderly patients with NCS and the abnormal AP/HR responses to orthostasis may be a feature specific to this population. Although the central mechanism of NCS is common to all ages, the age-related characteristics of the trigger event may indicate the need for specific management at different ages.