La majorite des patients se presentant aux urgences pour douleur thoracique aigue n’ont pas de modification significative de l’electrocardiogramme, du dosage de la troponine ou d’antecedents de cardiopathie ischemique. Les strategies diagnostiques ont pour objectif d’identifier les patients qui presentent ou vont developper un syndrome coronaire aigu dans ce sous-groupe considere comme a faible risque. Chez ces patients, l’objectif des explorations complementaires fonctionnelles ou morphologiques est l’exclusion de la maladie coronaire. Le scanner cardiaque a une sensibilite de 96 % avec un rapport de vraisemblance negatif de 0,09 et s’avere, en combinaison avec le dosage de la troponine ultrasensible, une technique hautement contributive au diagnostic avec le meilleur rapport cout-efficacite. La realisation d’un scanner cardiaque est indiquee en cas de douleur thoracique aigue avec un electrocardiogramme normal ou non contributif associe a un dosage de troponine ultrasensible negatif ou une modification modeste et lente. Le scanner cardiaque devrait etre realise idealement entre une heure et 72 heures apres la consultation initiale.

Une grande majorité des patients consultant pour douleur thoracique aiguë (DTA) aux urgences n’a pas de modifications ECG notables, ni d’histoire connue de maladie coronaire. Identifier le faible nombre de sujets qui ont, ou vont développer réellement un syndrome coronarien aigu (SCA) au sein d’un groupe considéré à faible risque demeure un vrai défi pour les cliniciens urgentistes. Chez ces patients, l’objectif du recours à un examen complémentaire d’imagerie non invasive, morphologique ou fonctionnelle est d’exclure le diagnostic de pathologie coronaire. Les performances diagnostiques contemporaines du coroscanner rapportent une sensibilité de 96 %, un rapport de vraisemblance négatif de 0,09, soit des valeurs très contributives en termes d’apport diagnostique et son intégration dans un algorithme décisionnel apparaît comme la stratégie la moins coûteuse, avec le meilleur rapport coût/efficacité. Le coroscanner est indiqué devant des douleurs thoraciques aiguës associées à des ECG non contributifs, en l’absence d’autres diagnostics évidents, lorsqu’il n’existe pas de détection de la troponine ultrasensible ou que les variations dynamiques de celle-ci sont modestes, lentes et/ou non concluantes. Le coroscanner devrait idéalement être effectué dans un délai de 3 à 48heures après la consultation initiale.

La majorite des patients se presentant aux urgences pour douleur thoracique aigue n’ont pas de modification significative de l’electrocardiogramme, du dosage de la troponine ou d’antecedents de cardiopathie ischemique. Les strategies diagnostiques ont pour objectif d’identifier les patients qui presentent ou vont developper un syndrome coronaire aigu dans ce sous-groupe considere comme a faible risque. Chez ces patients, l’objectif des explorations complementaires fonctionnelles ou morphologiques est l’exclusion de la maladie coronaire. Le scanner cardiaque a une sensibilite de 96 % avec un rapport de vraisemblance negatif de 0,09 et s’avere, en combinaison avec le dosage de la troponine ultrasensible, une technique hautement contributive au diagnostic avec le meilleur rapport cout-efficacite. La realisation d’un scanner cardiaque est indiquee en cas de douleur thoracique aigue avec un electrocardiogramme normal ou non contributif associe a un dosage de troponine ultrasensible negatif ou une modification modeste et lente. Le scanner cardiaque devrait etre realise idealement entre une heure et 72 heures apres la consultation initiale.

De part la progression démographique de nos sociétés et la prévalence croissante avec l’âge des coronaropathies, nous serons de plus en plus confrontés au traitement de l’infarctus ST+ des patients très âgés (> 90ans ?). Si les données scientifiques rigoureuses sont inexistantes dans ce cadre là, il existe de nombreux registres qui peuvent nous guider dans leur prise en charge. En premier lieu l’âge ne doit pas être en lui-même une contre-indication aux techniques de reperfusion classiques. Les recommandations ne mettent d’ailleurs pas de limite supérieure d’âge. L’angioplastie primaire dont le succès technique est identique aux populations plus jeunes est le traitement de choix et devra être pratiquée de préférence par abord artériel radial. L’alternative thrombolytique, validée pour les octogénaires, n’a pas été étudiée pour les plus âgés. Les complications hémorragiques, neurologiques, ischémiques et la mortalité hospitalière sont plus fréquentes que pour les populations plus jeunes, d’autant plus que l’altération hémodynamique initiale est importante, mais les survivants ont un pronostic vital identique, voire même meilleur que celui d’une population de même âge de référence. Ce qui en soi même justifie une adhésion maximale aux recommandations thérapeutiques en tenant compte des comorbidités et des insuffisances viscérales possibles.

Most patients presenting with acute chest pain (ACP) at the emergency unit do not have any marked electrocardiogram abnormalities or known history of heart disease. Identifying the few patients who have, or will actually develop acute coronary syndrome in this group that is considered to be at low risk, is an actual clinical challenge for emergency department physicians. In these patients, the goal of complementary non-invasive morphological or functional imaging tests is to exclude heart disease. The diagnostic values of coronary CT angiography include a sensitivity of 96% and a negative likelihood ratio of 0.09, which are highly contributory to the diagnosis, and the integration of this imaging test into a decision tree algorithm appears to be the least expensive strategy with the best cost/effective ratio. Coronary CT angiography is indicated in the presence of ACP associated with an inconclusive electrocardiogram, in the absence of any other obvious diagnoses, when the ultrasensitive troponin assay is negative or the dynamic changes are modest, slow and/or inconclusive. Ideally, coronary CT angiography should be performed within 3 to 48hours after the initial consultation.

Because of the demographic growth of our societies and the increasing prevalence of coronary artery disease with age, we will be increasingly faced with the treatment of myocardial ST+ very elderly patients (>90 years?). If evidence-based medicine does not exist within this framework, there are many registries that can guide us in their care. First, age should not in itself be an indication against reperfusion conventional techniques. In fact recommendations put no upper age limit. The primary angioplasty technical success, which is identical to the younger populations, is the treatment of choice and should be performed preferably by radial arterial access. The thrombolytic alternative, validated for octogenarians, has not been studied for older. Bleeding, neurological, ischemic complications and hospital mortality are more common than in younger populations, especially as the initial hemodynamic alteration is important, but the survivors have the same life-threatening or even better than that of a same reference population ages. Which in itself even justifies maximum adhesion to the therapeutic recommendations taking into account the co-morbidities and possible visceral shortcomings.

ISR out of 28 patients. So as a result for all patients included in our study, 13 patients from group (I) suffered ISR in the period of 6 months follow up period, they represented 40% of the group, while 14 patients in group (II) with a percentage of 42.4% of the group suffered ISR at 6 months. There was no statistically significant difference between the two groups as regard the incidence of ISR at follow up. (P > 0.05). Conclusions: We concluded that no significant statistical difference was found between the two stents (cobalt-chromium alloy bare metal stent versus conventional bare metal stainless steel stent) in diabetic patients regarding (initial procedural success, in-hospital complications, the incidence of ISR at follow up, event-free survival at follow up).

To determine the accuracy of prospective ECG-gated computed tomography coronary angiography (CTCA) using 256-slice scanner for detecting significant coronary artery disease (CAD) and to quantitatively estimate lumen narrowing with CTCA in comparison to invasive coronary angiography (ICA). Methods: This study included 109 consecutive patients who had ICA on the basis of a previous CTCA (within 60 days) for clinical suspicious of CAD. All CTCA scans were performed with a 256-slice scanner using prospective ECG-gated image acquisition. The presence of stenosis ⩾50%, measured by QCA for ICA and Visual assessment for CTCA, was considered significant stenosis. Results: Obstructive CAD was present in 73.4% of patients. On patient-based analysis, the sensitivity of CTCA was 98%, specificity 83%, PPV 94% and NPV 92%. For segment-based analysis, a total of 1584 segments were analyzed with a sensitivity of 89%, specificity 98%, PPV 85% and NPV 99%. High correlation was observed between degrees of luminal stenosis assessed by CTCA in comparison to QCA in all segments (r2 = 0.961). There was high agreement between observers regarding the presence of significant luminal stenosis (k = 0.78) and good correlation for percentage of luminal stenosis (r = 0.68, p < 0.001) between both readers. Conclusions: In a highly prevalence diseased population, prospective ECG-gated CTCA using 256-slice scanner is highly accurate for detection and quantification of the degree of coronary luminal stenosis in comparison to ICA.

Le recours a l’imagerie non invasive dans la strategie diagnostique des coronaropathies chroniques est recommande pour les patients presentant une probabilite de coronaropathie « intermediaire » apres examen clinique. L’utilisation des techniques d’investigation est discutee en fonction de la probabilite d’atteinte coronaire estimee a partir de l’examen clinique et des tests d’effort. Il existe deux types d’approche de detection de la maladie coronaire : la premiere, anatomique, est liee au pourcentage d’obstruction vasculaire (reduction du diametre ou de la surface luminale) et l’autre, physiologique, vise a authentifier la presence d’une ischemie myocardique secondaire a l’existence de ces lesions. Le scanner coronaire (coro-TDM) est une technologie recente ; sa place dans la strategie diagnostique n’a pas encore ete clairement determinee dans les recommandations des societes savantes. Nous discutons ici l’efficacite diagnostique de cette technique chez des malades pour lesquels on suspecte une coronaropathie chronique et de sa place actuelle dans le diagnostic de la maladie.

Coronary multislices CT (MDCT) has limited spatial and temporal resolution, which hampered the analysis of coronary artery (CA) segments. By increasing CA geometry the use of nitrates before acquisition could improve analysis quality, which is heart rate (HR) highly dependant. The aim of this study was to evaluate safety, hemodynamic effects and imaging efficacy of systematic use of sublingual nitroglycerin just before a 256 slices CA scanner acquisition. Thirty six consecutive patients had a coronary MDCT acquisition after 1 spray of sublingual nitroglycerin (NatisprayR 0.30 mg) (group 1). HR and mean arterial blood pressure (MBP) were measured before and after spray. Global imaging quality assessment, number of analyzable segments according to the syntax score segmentation, mean diameter and area of each segments was done by two blinded observers and compared to a control group of 36 consecutive patients (group 2) examined with the same machine, but without nitrates. Both groups were similar considering age, sex ratio, BMI and beta-blocker used. In group 1 nitrates did not change heart rate (62 ± 5 vs. 61 ± 4 bpm) nor MBP (100.7 ± 15 mmHg vs. 94.9 ± 12 mmHg). A total of 536 and 531 segments were analyzed respectively in group 1 and 2. Global imaging quality assessment was equal in both groups (good quality: 93.1% vs. 91.7%, group 1 and 2 respectively). There was <1% of missed segments in group 1 compared to 3% in group 2 (p = 0.002), this represents 2.1% vs. 7.2% of secondary segments, p = 0.03. Per segments mean diameter and area was greater in group 1 than group 2 (3.2 mm ± 0.1 vs. 2.8 mm ± 0.1, p < 0.0001; 8.6 mm 2 ± 0.3 vs. 6.2 mm 2 ± 0.3, p < 0.0001). Sublingual nitroglycerin significantly improves CA geometry and number of assessable segments, especially in smaller secondary segments, with no quality deterioration. Thus, sublingual nitrates should be systematically used before a coronary MDCT.

Radiation exposure after cardiac X-ray imaging: risk and prevention in daily practise Cardiac computed tomography (CT) angiography (CCTA) has emerged as a useful diagnostic imaging modality in the assessment of coronary artery disease. However, the potential risks due to exposure to ionizing radiation associated with CCTA, and generally with low-dose ionizing radiation (5 to 100 mSv) in the population have raised concerns. The effective dose (E), expressed in units of millisieverts (mSv), is a parameter meant to reflect the risk of the biological effects of ionizing radiation. The hypothetical complication of diagnostic medical radiation exposure that is of greatest concern, the risk of inducing malignancies, is a stochastic, or random, effect in which the interaction of radiation with cellular molecules may cause damage sufficient that a malignancy may result later (30 to 40 years after). Among hypotheses applied to the discussion of carcinogenesis at low radiation doses, the linear no-threshold hypothesis states that there is no threshold below which radiation cannot cause malignancies and that the risk of malignancies increases linearly with radiation dose. The consensus opinion in the BEIR VII report advocates the conservative approach of the linear no-threshold hypothesis. In that report and a prior report by the National Commission for Radiation Protection (ICRP), the age-and gender averaged lifetime risk of dying of a malignancy attributable to radiation exposure was estimated to be 5 to 7.9 in 100 individuals of the general population per 1 Sv of E. There is conflicting evidence regarding the potential presence and degree of carcinogenesis at the levels and types of radiation associated with medical imaging : The ICRP emphasizes that E is intended for use as a parameter in radiation protection and should not be used for epidemiological evaluation or for estimations of specific human exposures; Even though the accuracy of radiation-dose estimates and the relationship between the radiation dose received from cardiac imaging and the risk of malignancies may be uncertain, National and European regulation supports the concept of keeping patient doses as low as reasonably achievable (ALARA principle) but consistent with obtaining the desired medical information. A variety of algorithms for reducing dose in CCTA are available for use in daily practice. Most of the described dose-saving strategies can be combined, resulting in an efficacious reduction of overall radiation exposure. With updated technology, the measured E can be decreased to 1 MsV, much less than the dose recorded after conventional coronarography or SPECT.