L’échocardiographie à la dobutamine (EDS) est utilisée de façon courante comme un test non invasif d’ischémie indépendant de l’effort et visant à détecter la présence d’une atteinte coronaire et pour évaluer l’étendue de l’ischémie myocardique. Elle peut cependant être associée à du spasme coronaire. Dans cette étude, notre objectif est d’évaluer la prévalence et les facteurs prédictifs de spasme coronaire lié à la dobutamine chez les patients sans coronaropathie connue et avec des EDS faussement positives (test positif mais sans lésions coronaires significatives à la coro).Trois mille neuf cent cinquante-deux patients ayant bénéficié d’EDS dans notre laboratoire d’échographie entre janvier 2010 et mai 2012 ont été prospectivement évalués. Ceux avec une EDS positive ont bénéficié de coronarographies avec injection de méthylergotamine en cas d’absence de lésions coronaires ou de vasospasme spontané sévère. Les patients avec un spasme spontané sévère ou un test à la méthylergometrine positif mais sans lésions coronaires ont été inclus et comparés à ceux avec EDS positives mais sans lésions coronaires ni spasme (« vrais » faux positifs).Vingt-neuf patients avec spasme (19,4 % des EDS positives sans histoire coronaire) ont été comparés avec 56 patients sans lésions ni spasme (« vrais » faux positifs). Ils étaient plus souvent fumeurs (72,4 % vs 37,5 % ; p = 0,003) ; avaient plus souvent une dyslipidémie (79,3 % vs 43 % ; p = 0,001) ; ils avaient une aire ischémique en pic de stress plus importante (3,4 segments vs 2,7 segments ; p = 0,05). En analyse multivariée, la dyslipidémie (HR = 10,7 ; 95 % CI = [2,7–42,1] ; p = 0,001) et le tabagisme actif (HR = 6,1 ; 95 % CI = [1,7–21,1] ; p = 0,004) étaient les facteurs prédictifs indépendants de spasme coronaire plutôt que de « vrais » faux positifs.Le spasme coronaire lié à la dobutamine est présent chez une proportion significative des patients étiquetés faux positives et devraient systématiquement être recherchés. La dyslipidémie et le tabagisme actifs sont les 2 facteurs prédictifs indépendants de spasme plutôt que de fausse positivité.Dobutamine stress echocardiography (DSE) is being consistently used as an exercise-independent stress modality aimed at the detection of coronary artery disease (CAD) and the evaluation of myocardial ischemia. It may though occasionally induce coronary vasospasm. In this study, we aimed to evaluate the prevalence and predictors of dobutamine-related coronary spasm in patients without known CAD and false positive DSE (positive DSE but no significant coronary lesions on angiogram).Three thousand nine hundred and fifty-two patients referred to our echocardiography laboratory for DSE between January 2010 and May 2012 were prospectively investigated. Those with positive DSE underwent coronary angiograms with systematic methylergometrine intracoronary injection in case of absence of significant coronary stenosis or spontaneous occlusive coronary spasm. Patients with spontaneous occlusive coronary spasm or positive methylergometrine test but no significant stenoses were enrolled and compared with those with positive DSE but no coronary lesions nor spontaneous or induced spasm (“true” false positive DSE).Twenty-nine patients with DSE-related vasospasm (19.4% of positive DES without known CAD) were compared with 56 patients with no lesions and no spasm (“true” false positive DSE). They were more frequently smokers (72.4% vs 37.5%; P = 0.003); they had more frequently dyslipidemia (79.3% vs 43%; P = 0.001); they also had a larger ischemic area at peak DSE (3.4 segments vs 2.7 segments; P = 0.05). On multivariate analysis, dyslipidemia (HR = 10.7; 95% CI = [2.7–42.1]; P = 0.001) and active smoking (HR = 6.1; 95% CI = [1.7–21.1]; P = 0.004) were found to be independent predictors of spasm-related DSE rather than “true” false positive DSE.DSE-related coronary spasm is present in a significant proportion of patients with erroneously labelled “false” positive DSE and should systematically be ruled out. Dyslipidemia and active smoking were independent predictors of spasm rather than “true” false positive DSE.

OBJECTIVE:Our purpose was to compare the blood pressure response to short-term treatment with captopril or trandolapril in patients with left ventricular (LV) dysfunction after acute myocardial infarction (AMI).METHODS:A multicenter, randomized, double-blind, double-dummy, parallel group study was performed. Treatment was initiated 3 to 10 days after the onset of symptoms. On day 1, patients received a single dose of captopril 6.25 mg, trandolapril 0.5 mg, or placebo in the morning. Treatment was then titrated upward over the next 5 days. Blood pressure was monitored with an automated device for the first 12 hours after dosing on day 1. Conventional blood pressure measurements were performed throughout the study.RESULTS:Of 205 patients treated in the study, 193 patients were evaluated for first-dose effects. In the captopril group, the maximum decrease in blood pressure occurred after 2 hours, and the magnitude of this decrease was significantly greater than in the other 2 groups: 8.8 +/- 12/6.3 +/- 8 mm Hg (captopril) versus 5.4 +/- 10/3.1 +/- 8 mm Hg (trandolapril) versus 2.4 +/- 9/1.4 +/- 7 mm Hg (placebo) (P <.01). In the trandolapril group, the maximum decrease occurred after 7 hours and the magnitude of this effect was similar in all 3 groups: 5.9 +/- 11/3.6 +/- 8 mm Hg (trandolapril) versus 4.3 +/- 10/3.5 +/- 8 mm Hg (captopril) versus 3.1 +/- 11/2.8 +/- 8 mm Hg (placebo) (not significant). Although there was a higher incidence of hypotension on day 1 in the captopril group, the overall incidence of hypotension during the study period was similar in both active treatment groups.CONCLUSION:Because of differences in initial blood pressure response profiles, short-term treatment with trandolapril tended to be better tolerated than captopril in post-AMI patients with LV dysfunction.

In a randomized trial, we compared topical anesthesia by a lidocaine-prilocaine cream (EMLA[registered sign]; Laboratorie ASTRA, Manterre, France) with subcutaneous local lidocaine infiltration for radial artery cannulation. Patients included 538 adults scheduled for coronary angiography using a radial approach. EMLA[registered sign] was applied 2 h before radial cannulation, and lidocaine infiltration was performed 5 min before cannulation. The primary end point was pain as assessed by a verbal numerical scale (0 = no pain, 10 = extreme pain). Pain was less severe in the EMLA[registered sign] group than in the lidocaine infiltration group (Score of 2 vs 7; P = 0.0001). Additional lidocaine infiltration was required significantly less frequently in the EMLA[registered sign] group (relative risk 0.19). The failure rate of cannulation was significantly lower in the EMLA[registered sign] group (relative risk 0.38), and insertion time was shorter (4 versus 6 min). We conclude that EMLA[registered sign], compared with lidocaine infiltration, reduces pain associated with radial artery cannulation and improves the success rate of the procedure. Routine application of EMLA[registered sign] should be performed in awake patients 2 h before radial artery cannulation. Implications: In a randomized trial, we compared topical anesthesia by a lidocaine-prilocaine cream (EMLA[registered sign]) with subcutaneous local lidocaine infiltration for radial artery cannulation in 538 adults patients. EMLA[registered sign] reduced pain associated with radial artery cannulation and improved the success rate of the procedure. (Anesth Analg 1998;87:403-6)

La frequence des occlusions coronaires parmi les survivants d’arrets cardiaques extrahospitaliers et la valeur diagnostique de l’electrocardiogramme et de la clinique recueillis en prehospitalier etaient inconnues. Une etude prospective a donc ete menee de facon conjointe par le SAMU de Paris et les services de cardiologie et de reanimation medicale de l’hopital Cochin : de septembre 1994 a aout 1996, tout survivant d’un arret cardiaque extrahospitalier âge de 30 a 75 ans et sans cause extracardiaque evidente d’arret est propose pour coronarographie immediate avec angioplastie de desocclusion eventuelle. Quatre-vingt-quatre patients (70 hommes, âge moyen : 55,5 ans ± 11,5) ont ete etudies. Une occlusion coronaire a ete trouvee chez 40 patients (48 %) et une angioplastie tentee chez 37, avec un succes primaire chez 28. La valeur predictive positive et negative pour l’occlusion coronaire de l’electrocardiogramme (sus-decalage) et de la clinique (douleur thoracique) est mediocre ; la survie hospitaliere est de 38 %. Par analyse multivariee, les facteurs predictifs independants de survie sont : une angioplastie reussie, l’absence d’utilisation d’adrenaline pendant le transport et surtout un delai court entre l’arret et la reprise d’une hemodynamique satisfaisante. La mise en place de ce nouveau maillon cardiologique dans la chaine de survie semble donc ameliorer la prise en charge des survivants d’un arret cardiaque extrahospitalier. Le pronostic reste cependant domine par les delais initiaux d’intervention.

10. coronary arteries: notes on technical aspects. Cathet Cardiovast Diagn 1990,21:106-11. Bass TA, Miller AB, Rubin RM, Stowers SA, Perryman RA. Transluminal angioplasty of anomalous coronary arteries. AM HEART J 1986;112:610-3. Goulah RD, Goldstein JE, Hart JI. PTCA in anomalous coronary artery. New NJ Med 1989;86:548-50. Schwartz L, Aldridge HE, Sesrle C, Csepio R. Percutaneous transluminal angioplasty of an anomalous left circumflex coronary artery arising from the right sinus of Valsaiva. Cathet Cardiovasc Diagn 1982;8:623-4. Kimbiris D, Lo E, Iskandrian A. Percutaneous transluminal coronary angioplasty of anomalous left circumflex artery. Cathet Cardiovasc Diagn 1987;13:407-10. Rivitz SM, Garratt KN. Stenotic anomalous circumflex artery causing myocardial infarction following angioplasty of a right coronary artery stenosis. Cathet Cardiovasc Diagn 1989;17: 105-8.