Genetic Polymorphisms and Coronary Artery Disease in the South of France

Vascular disease is a multifactorial disease that involves atherosclerotic and thrombotic factors. Genetic polymorphisms have been associated with myocardial infarction and angina pectoris. The aim of the present study was to assess the relationship between some genetic polymorphisms and myocardial infarction (MI) or vasospastic angina pectoris in a population from southern France. Genetic polymorphisms of the renin angiotensin system (the D/I polymorphism of the ACE gene and the A1166C polymorphism of the angiotensin II type 1 receptor [AT1R]) and of haemostatic factors (the -675 4G/5G polymorphism of the plasminogen-activator inhibitor 1 [PAI-1] gene, and the G to T common point mutation in exon 2, codon 34 of the Factor XIII A-subunit gene) were examined.

We assessed the genotype distribution in consecutive coronary artery disease (CAD) patients with MI (n = 201) and vasospastic angina pectoris (n = 43) and in 244 healthy controls comparable in age, sex, body mass index and total cholesterol level.

The genotype distribution of AT1R polymorphism was significantly different between controls and patients, the prevalence of the C allele carriers being higher in patients with MI after the age of 45 than in control individuals (61 vs 45%, p <0.01), leading to an odds ratio (OR) of 2 (CI: 1.2-3.4). When looking at the group of patients with vasospastic angina the difference was even higher (76 vs 45%, p <0.01) yielding an OR of 4.3 (CI: 1.4-17.4). Genotype distributions of ACE, PAI-1 and Factor XIII polymorphisms were similar in patients and in controls.

This study is in favor of a role of AT1R gene polymorphism in myocardial infarction and vasospastic angina.

[Does diabetes change the anti-ischemic therapeutic options in the symptomatic coronary patient?]

The assessment of results of medical treatment, angioplasty and coronary bypass surgery in diabetic coronary patients is difficult because of the absence of distinction in the subgroups of type 1 and 2 diabetes and of stable and unstable angina. With respect to medical therapy, betablockers are practically without deleterious effects and are effective in diabetic populations. The same is true of other antianginal drugs. Conventional coronary angioplasty is associated with poorer results than the general population in the long-term, partly because of progression of the coronary artery disease and partly because of an increased incidence of restenosis. The use of stents improves these results, which are similar to those of the general population with single vessel disease or those without proteinuria. Coronary bypass surgery, despite a certain perioperative morbidity, is associated with an identical survival rate at 5 years as non-diabetics, providing the internal mammary artery is grafted. The comparison between these methods is resumed in the ACIP study which opposes the 3 strategies, in Morris et al's study comparing medical and surgical approaches and, finally, in the recent BARI trial where patients were randomly allocated to angioplasty or surgery. It would appear that the surgical strategy gives better results in multivessel disease. However, many reserves have been voiced because of the small numbers of patients, the high number of excluded patients and the fact that recent progress in angioplasty with widespread use of stenting associated with the prescription of new antiaggregant drugs was not taken into account.

Genetic polymorphisms and coronary artery disease in the south of France

Vascular disease is a multifactorial disease that involves atherosclerotic and thrombotic factors. Genetic polymorphisms have been associated with myocardial infarction and angina pectoris. The aim of the present study was to assess the relationship between some genetic polymorphisms and myocardial infarction (MI) or vasospastic angina pectoris in a population from southern France. Genetic polymorphisms of the renin angiotensin system (the D/I polymorphism of the ACE gene and the A1166C polymorphism of the angiotensin II type 1 receptor [AT1R]) and of haemostatic factors (the -675 4G/5G polymorphism of the plasminogen-activator inhibitor 1[PAI-1] gene, and the G to T common point mutation in exon 2, codon 34 of the Factor XIII A-subunit gene) were examined. We assessed the genotype distribution in consecutive coronary artery disease (CAD) patients with MI (n = 201) and vasospastic angina pectoris (n = 43) and in 244 healthy controls comparable in age, sex, body mass index and total cholesterol level. The genotype distribution of AT1R polymorphism was significantly different between controls and patients, the prevalence of the C allele carriers being higher in patients with MI after the age of 45 than in control individuals (61 vs 45%, p <0.01), leading to an odds ratio (OR) of 2 (CI: 1.2-3.4). When looking at the group of patients with vasospastic angina the difference was even higher (76 vs 45%, p <0.01) yielding an OR of 4.3 (CI: 1.4-17.4). Genotype distributions of ACE, PAI-1 and Factor XIII polymorphisms were similar in patients and in controls. This study is in favor of a role of ATIR gene polymorphism in myocardial infarction and vasospastic angina.

Fatal cerebral hemorrhage and severe thrombocytopenia during abciximab treatment

We describe the case of a fatal cerebral hemorrhage associated with a severe thrombocytopenia (4.0 x 10(9)/l), occurring only 90 min after starting treatment with abciximab, in a patient undergoing primary percutaneous transluminal coronary angioplasty (PTCA) for an acute myocardial infarction. Cathet. Cardiovasc. Intervent. 49:177-180, 2000.

[Acute complications of coronary angioplasty: prevention and management]

The immediate results of transluminal coronary angioplasty (TCA) have improved considerably during recent years. Balloon dilatation of the arterial stenosis is the basis of this technique of revascularisation but new tools may be used to treat specific lesions. Coronary occlusion is the most feared complication of TCA. It may cause myocardial infarction or death of the patient. It is usually secondary to dissection and/or thrombus of the artery. The implantation of a stent successfully treats most cases of dissection. New anti-platelet (GP IIb/IIIa) drugs seem to be very effective in the prevention and treatment of the thrombosis. The systematic use of ticlopidine limits the risk of stent occlusion. Improved features enable satisfactory implantation of stents in the majority of cases. In some patients, the clinical consequences of occlusion may be limited by vascular bypass techniques, especially intra-aortic balloon pumping. In other cases, emergency coronary bypass surgery may be necessary. When TCA is considered to be a very high risk procedure, effective surgical cover is essential.

Silent myocardial ischemia in patients with diabetes: who to screen

OBJECTIVE

Silent myocardial ischemia (SMI) is more common in diabetic patients than in the general population. However, the exact prevalence of SMI is not known, and routine screening is costly. The purpose of this 1-year study was to estimate the prevalence of SMI and define a high-risk diabetic population by systematically testing patients with no symptoms of coronary artery disease (CAD).

RESEARCH DESIGN AND METHODS

The criteria for inclusion in this study were age (between 25 and 75 years), duration of diabetes (>15 years for type 1 diabetes, 10 years for type 2 diabetes with no cardiovascular risk factors, and 5 years for type 2 diabetes with at least one cardiovascular risk factor), and absence of clinical or electrocardiogram (ECG) symptoms of CAD. For 1 year, 203 patients were screened, including 28 women and 45 men with type 1 diabetes (aged 41.5+/-10.9 years, mean duration of diabetes 20.9+/-7.7 years [mean +/- SD]) and 61 women and 69 men with type 2 diabetes (aged 60.7+/-8.7 years, duration of diabetes 16.5+/-7.1 years). Exercise ECG was the first choice for screening method. If exercise ECG was not possible or inconclusive, thallium myocardial scintigraphy (TMS) with exercise testing and/or dipyridamole injection was performed. If any one of these tests was positive, coronary angiography was carried out and was considered to be positive with a stenosis of > or =50%.

RESULTS

Positive screening results were obtained in 32 patients (15.7%). Coronary angiography demonstrated significant lesions in 19 patients (9.3%) and nonsignificant lesions in 7 patients (1 false-positive result for exercise ECG and 6 false-positive results for TMS). Coronary angiography was not performed in six patients. All but 3 of the 19 patients (15 men and 4 women) in whom silent coronary lesions were detected presented with type 2 diabetes. The main differences between the 16 type 2 diabetic patients presenting with coronary lesions and the type 2 diabetic patients without SMI were a higher prevalence of peripheral macroangiopathy (56.2 vs. 15.1%, respectively, P < 0.01) and a higher prevalence of retinopathy (P < 0.05). No correlation was found between SMI and duration of diabetes, HbA1c level, renal status, or cardiovascular risk factors except for family history of CAD.

CONCLUSIONS

The results of this study allowed us to determine a high-risk group for SMI in the diabetic population. SMI with significant lesions occurs in 20.9% of type 2 diabetic male patients who are totally asymptomatic for CAD. Based on these findings, we recommend routine screening for male patients in whom the duration of type 2 diabetes is >10 years or even less when more than one cardiovascular risk factor is present.

Direct evidence of endothelial injury in acute myocardial infarction and unstable angina by demonstration of circulating endothelial cells

Circulating endothelial cells (CECs) have been detected in association with endothelial injury and therefore represent proof of serious damage to the vascular tree. Our aim was to investigate, using the technique of immunomagnetic separation, whether the pathological events in unstable angina (UA) or acute myocardial infarction (AMI) could cause desquamation of endothelial cells in circulating blood compared with effort angina (EA) and noncoronary chest pain. A high CEC count was found in AMI (median, 7.5 cells/mL; interquartile range, 4.1 to 43.5, P <.01 analysis of variance [ANOVA]) and UA (4.5; 0.75 to 13.25 cells/mL, P <.01) within 12 hours after chest pain as compared with controls (0; 0 to 0 cells/mL) and stable angina (0; 0 to 0 cells/mL). CEC levels in serial samples peaked at 15.5 (2.7 to 39) cells/mL 18 to 24 hours after AMI (P <.05 repeated measures ANOVA), but fell steadily after UA. Regardless of acute coronary events, the isolated cells displayed morphologic and immunologic features of vascular endothelium. The CECs were predominantly of macrovascular origin. They did not express the activation markers intercellular adhesion molecule (ICAM)-1, vascular cell adhesion molecule (VCAM)-1, and E-selectin, although some were positive for tissue factor. CECs failed to exhibit characteristics of apoptosis (TUNEL assay) excluding this event as a possible mechanism of cell detachment. The presence of CECs provides direct evidence of endothelial injury in AMI and UA, but not in stable angina, confirming that these diseases have different etiopathogenic mechanisms.

[Prospective study on the mechanism of myocardial infarction without significant coronary stenosis]

The aim of this study was to evaluate prospectively the respective roles of the atheromatous plaque, coronary spasm and abnormalities of haemostasis in patients with myocardial infarction with normal coronary arteries. The study population included 25 patients (19 men and 6 women) with a mean age of 52.1 +/- 11.1 years (34-76 years). The diagnosis of myocardial infarction was made as the finding of 2 out of 3 WHO criteria. It occurred spontaneously and was transmural in 80% of cases, inferior wall infarction in 9 patients (36%), anterior in 12 (48%) and lateral in 4 patients (16%). All patients underwent investigation on average 10 days after infarction (1-42 days) by coronary angiography with quantitative angiography, endocoronary ultrasonography, an ergometrine provocation test for coronary spasm and a blood coagulation study. Coronary angiography was normal in 4 patients but showed wall changes without stenosis > 50% in 20 patients and one case of aneurysmal arterial disease. Intracoronary thrombosis was detected in 6 cases. Endocoronary ultrasonography confirmed the normality of the coronary arteries in 2 cases and showed atheroma in 23 cases (soft atheroma: n = 17 and hard: n = 6). It detected 66% of the coronary thrombi observed at angiography and found 3 other cases. Coronary spasm was verified in 10 patients (40%). The coagulation study was normal in 19 patients and showed increase in Pai-1 in 5 patients and primary thrombocythemia in one case. The authors conclude that coronary angiographic data is less accurate than endo-coronary ultrasonography which best shows the extent and, above all, the nature of the plaques present in 23 of the cases (92%). Coronary spasm may be a contributing factor in 40% of cases, in situ thrombosis in 36% of cases despite usually normal blood clotting studies. None of these abnormalities was observed in one case. The embolic cause of infarction was certain in 2 cases.

[Detection and surveillance of left atrial thrombosis by transesophageal echocardiography]

Out of 1,141 successive transoesophageal echocardiographic studies performed prospectively between 01/05/1993 and 31/12/1995, 26 cases of left atrial thrombosis were observed (2.2%); 5 were in the left atrium (20%), 19 in the left atrial appendage (73%) and the thrombi were in both atrium and left atrial appendage in 2 cases (7%). The 26 patients included 15 women and 11 men, with an average age of 69 +/- 16 years (range 25-89 years); 22 patients (84%) had permanent atrial fibrillation and 4 were in sinus rhythm. Only 5 of the patients were on oral anticoagulant therapy. All had underlying cardiac disease: 11 mitral valve diseases; 10 dilated cardiomyopathies; 2 hypertrophic cardiomyopathies; 3 other cardiac diseases. The indication for transoesophageal echocardiography was systemic embolism in 13 cases (50%); before D.C. cardioversion in 10 cases (38%) and before percutaneous mitral valvuloplasty in 3 cases. The thrombus was adherent in 18 cases (69%) and mobile in 8 cases (31%). Spontaneous contrast was observed in 23 cases (88%). Intravenous heparin was given as soon as the diagnosis was made. In 4 patients, thrombectomy was indicated in view of the threatening nature of the thrombus and/or the necessity for associated valve replacement. In 22 patients, heparin was relayed by oral anticoagulants on the 10th day of treatment. Control transoesophageal echocardiography was not performed because of the patient's refusal or poor general condition. The other 15 patients were reexamined 1 to 5 times between the 4th day and 12th month: a regression was observed in 13 cases (86%) which was complete in 11 and partial in 2 cases. No cases of embolism occurred during follow-up but six patients died: 1 of the operated cases and 5 of the patients treated medically (3 cardiac failures and 2 cerebral haemorrhages). The authors conclude that left atrial thrombosis is rare in the absence of classical embolic cardiac disease. With the exception of the surgical indication of a life-threatening thrombus and/or associated surgical mitral valve disease, anticoagulant therapy results in complete or partial regression of the thrombus visualised by transoesophageal echocardiography which is essential for follow-up. The prognosis depends on the severity of the underlying heart disease.

[Heart rate variability and vagal syncope in the young adult]

Heart rate variability is a sign of sympathetic activity. The authors compared two study populations of young males aged 19 to 30 years: population T comprised 15 healthy volunteers who had two negative tilt tests, one under basal conditions and the other after a bolus of isoproterenol; population S comprised 12 patients without cardiac or other disease, who were followed up for malaise and in whom the basal tilt test was positive, confirming the vagal origin of syncope. Temporal and spectral (total power, low frequency 0.04-0.15 Hz, hight frequency 0.16-0.40 Hz) data was obtained concerning heart rate variability from 24 hour Holter monitoring. The main difference between the two study populations was in the temporal data over 24 hours especially with respect to the heart rate (T = 73.5 +/- 6.9; S = 65.4 +/- 6.2/min; p = 0.004) and the percentage of successive R-R intervals varying by more than 50 ms (PNN 50) (T = 20.2 +/- 8.3%; S = 30.7 +/- 10.2%; p = 0.024). At night, the lowest SDANN/5 (standard deviation of RR intervals over periods of 5 minutes) were observed in group S (67.2 +/- 16.7 ms vs 87.3 +/- 24.4 ms; p = 0.026). No statistically significant differences between the two groups was observed in the spectral data. The temporal data of heart rate variability on Holter ECG monitoring over 24 hours could therefore have a good predictive value of the vagal origin of syncope in young adults.

[Frequency and nature of atheroma at the site of spasm of angiographically normal or subnormal coronary arteries: an endocoronary ultrasonographic study]

Anatomical studies suggest that sites of coronary spasm are subject to early atherosclerosis. Coronary angiography is unable to confirm the lesions or provide information about their nature. On the other hand, endocoronary ultrasound is able to identify and, it is hoped, to determine the frequency and composition of the lesions. Nineteen patients with chest pain and angiographically normal or subnormal coronary arteries were included in a prospective study (16 men and 3 women: average age 53 +/- 10 years). Four patients had spontaneous spasm and in the other 15, spasm was induced by intravenous injection of ergometrine (6 micrograms/kg). After countering the spasm with isosorbide dinitrate, the site of spasm and adjacent segments were examined by endocoronary ultrasound. Localised vasospasm which was stenotic in 14 cases and obstructive in 5 cases, was observed. The ECG was unchanged in 4 cases and showed ST-T segment changes in 15 cases. The artery affected was the left anterior descending in 10 cases, the left circumflex in 2 cases and the right coronary in 7 cases. A plaque of atheroma, defined as significant intimal thickening, was detected in 18 out of the 19 cases. This atheroma was classified as soft in 17 cases and hard in one case. The authors conclude that vasospasm is not only associated with a plaque of atheroma, nearly always suspected at coronary angiography, but also its composition is nearly always soft (lipidic) from ultrasonographic data.

Tilt table testing of young adult patients: improved speed and sensitivity using an isoproterenol bolus and a continuous 60 degrees tilt

The tilt table is a diagnostic device used to induce vagal syncope and determine etiology. Sensitivity enhancing techniques, such as the administration of isoproterenol, can be applied to children and young adults to compensate for the otherwise low sensitivity (20%-30%) observed in that population. This study describes an improved test that offers a simplified approach while decreasing the amount of time involved by up to 50%, without compromising sensitivity. This 45-minute procedure relies on sensitization with isoproterenol administered as a 2- to 80 micrograms bolus instead of a continuous infusion. The isoproterenol is injected at the 30th minute of a 45-minute 60 degrees tilt test without returning the patient to the supine position. In this study, the isoproterenol bolus tilt test was found to be "positive" in 24 of 30 patients reporting unexplained syncope: 10 cases before the 30th minute (11.2 +/- 8.4 min) and 14 cases after administration of 5.1 +/- 1.9 micrograms of isoproterenol.

Clinical epidemiology of venous thromboembolic disease. Results of a French Multicentre Registry

OBJECTIVE

Between July 1992 and December 1994, 16 French hospital centres, mainly cardiological, participated in a non-controlled observational study on venous thromboembolic disease. The objective of this survey was to collect data concerning the current status of pulmonary embolism and deep venous thrombosis.

PATIENTS

During this period, 547 patients were included: 446 with deep venous thrombosis and 387 with pulmonary embolisms.

RESULTS

Mean age of patients was 63 +/- 21 years. There were no significant differences between the sexes. Pulmonary embolism and deep venous thrombosis tended to occur more frequently during the autumn and winter. In 30% of cases, prior deep venous thrombosis or pulmonary embolism was noted. No cause was found for the condition in 47% of cases. Ultrasound (echocardiography and/or venous ultrasound) was the most frequently requested investigation. Intravenous heparin remains the most widely used treatment (76%). Oral anticoagulation was begun before day 3 in less than 31% of cases. Thrombolytic treatment was used in 20% of pulmonary embolism cases, but was rarely prescribed for deep venous thrombosis (2.2%). The hospital recurrence rate (12/547 cases) was fairly low. The search for occult malignancy, performed in 48% of cases, seems to remain one of the major concerns of physicians. The combined pulmonary embolism and deep venous thrombosis mortality rate was 4.4%, while the death rate for pulmonary embolism alone was 6.2%.

Clinical electrophysiologic effects of a single high oral dose of amiodarone

Several recent reports have described the antiarrhythmic effects of a single high oral dose of amiodarone but clinical electrophysiologic effects have not been reported. The present study was performed to assess electrophysiologic effects in 12 patients. After baseline electrophysiologic studies (EPS) patients were administered a single oral dose of 30 mg/kg of amiodarone. EPS was repeated 7.5 +/- 0.5 hours later. Plasma levels of amiodarone and its metabolite desethylamiodarone were determined at the time of the second EPS, Holter monitoring was performed for 24 hours after amiodarone administration. Amiodarone significantly increased the following parameters: corrected QT interval (+4.5%), functional refractory period of the right atrium (+7%); AH interval (+12.3%), effective refractory period of the atrioventricular node (+18.5%), and cycle length of Wenckebach block (+8.4%). These effects were not correlated with plasma levels of amiodarone and desethylamiodarone. Holter monitoring detected no significant bradycardia or arrhythmia. These findings indicate that the effects of a single high oral dose of amiodarone are the same as those known to be induced by acute intravenous administration.

Coronary artery spasm in patients with normal or near normal coronary arteries. Long-term follow-up of 277 patients

Most studies on the natural course of coronary artery spasm in patients with normal or nearly normal coronary arteries are based on medium-term follow-up in small populations. The present series includes 277 successive patients with a median follow-up of 89 months (range: 1 to 198 months). There were 206 men and 71 women whose mean age was 53.6 +/- 9.3 years. They were all assessed with coronary arteriography which revealed no stenoses greater than 50%. Spasm was confirmed during the coronary arteriography in 157 patients (56.7%), by a positive provocation test following the arteriography in 113 patients (40.8%), and by an electrocardiogram which showed Prinzmetal's variant angina in seven patients (2.5%). The majority of patients, 264 (95.3%) were treated with calcium channel blockers. At the end of this study: 35 patients (12.6%) were lost to follow-up; 20 patients (7.2% died) including 10 (3.6%) from cardiac causes; 18 patients (6.5%) experienced myocardial infarction in 11 of whom repeat coronary arteriography consistently demonstrated one or more significant stenoses (greater than 70%); 109 patients (39%) had persistent angina, in 52 of whom the severity (more than one episode per month) warranted repeat coronary arteriography which detected significant stenosis in 19 cases; 95 patients (34.3%) were asymptomatic. Multivariate statistical analyses showed that only predictors of major coronary events (death, myocardial infarction or angina requiring repeat coronary arteriography) were systemic hypertension or the finding of minor parietal irregularities on the initial coronary arteriogram. Conclusion. Despite treatment with calcium channel blockers, persistent or recurrent episodes of angina are frequently observed whereas complications such as myocardial infarction or death are rare.

[Pulmonary arteriovenous fistula. A rare cause of dyspnea and cyanosis in an adult]

The authors report the case of a pulmonary arteriovenous fistula presenting with dyspnoea and cyanosis in a young adult. The malformation was situated on the proximal pulmonary vessels and was cured by surgical correction. The diagnostic value of the clinical signs and complementary investigations of this rare conditions, often detected during adulthood, is discussed. The functional tolerance of the condition is often variable. Oxygen desaturation of arterial blood indicates a right-to-left shunt. Pulmonary angiography enables visualisation of the lesions and guides surgical management. The prevalence of complications of this condition is not well known, but the potential severity is an argument for therapeutic intervention. Embolisation techniques are developing but there is a risk of a systemic embolism. Surgery is the reference for the treatment of proximal fistulae, its curative effect being immediate and definitive.

[Spasm of normal or irregular coronary arteries. Long-term outcome of 277 patients]

The outcome of patients presenting with spasm of normal or subnormal coronary arteries is only known in small series of patients at medium-term. The authors reviewed the outcome of 277 successive patients over an average period of 86 +/- 43 months (12 to 174 months). There were 206 men and 71 women with a mean age of 54 +/- 9 years. Coronary angiography was performed in all cases and did not show any stenosis greater than 50%. Spasm was documented during coronary angiography in 157 cases (57%) by a positive Methergin test after coronary angiography in 113 cases (41%) and by an ECG recording of Prinzmetal angina in 7 cases (2.5%). Nearly all patients (264: 95%) were treated by calcium antagonists. At the end of follow-up, there were: 35 lost to follow-up (12.6%), 20 deaths (7.2%) of which 10 were cardiac (3.6%), 18 myocardial infarctions (6.5%): 11 had repeat coronary angiography which showed one or more new significant (> 70%) coronary lesions in all cases; 109 patients had persistence of chest pain (39%). The severity of symptoms in 52 cases (over one attack of chest pain per month) led to repeat coronary angiography which showed significant coronary disease in 19 cases; 95 patients (34%) were asymptomatic. A multivariate statistical analysis showed hypertension or subnormal appearances on the initial coronary angiography to be significant predictive factors for new coronary events (death, myocardial infarction or angina requiring repeat coronary angiography). The authors conclude that coronary spasm of angiographically normal or subnormal arteries is only well controlled at long-term in 39% of patients not lost to follow-up and is responsible for death or myocardial infarction in 11.6% of cases (nearly 1.5% per year).

[Detection of circulating endothelial cells: a new diagnostic test of angina at rest]

The diagnosis of spontaneous angina depends on the recording of per-critical electrocardiographic changes. There is no simple biological test to make its retrospective diagnosis. The attack is usually triggered by instability of an atheromatous plaque which fissures and liberates endothelial cells in the blod stream. The detection of these cells cold therefore be a biological sign of this condition. The technique of detection of circulating endothelial cells by immuno-magnetic method was used in 3 groups of patients admitted to hospital within 24 hours: group I comprised 11 patients with acute myocardial infarction, group II comprised 23 patients who had suffered from spontaneous angina with ST segment depression during the attack and significant coronary arterial stenosis, group III comprised 6 patients with chest pain for which coronary angiography is normal and provocative test of spasm is negative. Circulating endothelial cells were detected in all patients of group I (100%), in 18 of the 23 patients of group II (78%) and only in one of group III (18%). These results confer on this biological test for spontaneous angina a specificity and predictive positive value of 83 and 95% and a sensitivity and negative predictive value of 78 and 50%. Therefore the detection of circulating endothelial cells could be used as a simple and reliable test for retrospective diagnosis of spontaneous angina. The mediocre sensitivity and negative predictive value may be explained by a mechanism other than fissuration of atheromatous plaque in some cases of spontaneous angina.

[Treatments of acute myocardial infarction other than recanalization ]

During the past 15 years, the in-hospital mortality of patients with acute myocardial infarction has considerably declined. The 2 main reasons for this decrease in mortality have been the introduction of intensive coronary care units, and reperfusion of myocardial infarction, either by coronary thrombolysis or percutaneous transluminal coronary angioplasty. However benefits of other therapies should not be overlooked. General care measures should include: close supervision, bed rest, liquid diet, analgesics, reduction of anxiety, oxygen therapy, intravenous heparin and aspirin, monitoring of blood pressure and heart rate. beta-blockers and angiotensin-converting enzyme inhibitors, combined or not with thrombolytic therapy, are also available to reduce the rate of mortality and morbidity. The benefits to be expected from these 2 medications combined have not yet been demonstrated, so that it appears reasonable in common practice to choose either drug according to the patient's functional state.

[Comparison of the antispastic effect of Bi-Tildiem 120 mg and Tildiem 60mg]

Diltiazem (Tildiem 60 mg) is a calcium channel blocker with demonstrated efficacy and safety in the treatment of stable angina pectoris and spastic angina. The sustained release formulation of diltiazem, allowing two daily doses (Bi-Tildiem 120 mg), is already marketed in France for the treatment of stable angina. It was therefore interesting to evaluate the efficacy and safety of this form, administered in two daily doses, in coronary spasm, versus the classical formulation, Tildiem 60 mg, given at the same daily dose, i.e. 240 mg, in three divided doses per day. We conducted a single-centre, randomized, double-blind, cross-over clinical study in twelve patients, eleven men and one woman, between the ages of 42 and 70 years, presenting with angina and normal coronary arteries and spasm documented by a positive methylergonovine (Methergin) test. They were divided into two groups of six patients receiving either Tildiem followed by Bi-Tildiem, or Bi-Tildiem followed by Tildiem. The characteristics of the two groups were comparable at the time of the selection visit. The methylergonovine test, used to assess the efficacy of the two treatments, was improved by Tildiem and Bi-Tildiem compared to the placebo test (p = 0.001 and 0.002), without any significant difference between Tildiem and Bi-Tildiem: an improvement was obtained in 11/12 and 10/12 patients, respectively. No deterioration of the test was observed with Tildiem or Bi-Tildiem compared to placebo. The coronary symptoms and blood diltiazem levels were similar with Tildiem and Bi-Tildiem. The results confirmed the safety of Bi-Tildiem. A single adverse effect was attributed to treatment: an episode of mild insomnia. No serious adverse effect were observed and none of the patients discontinued the study. The efficacy and safety of Tildiem and Bi-Tildiem are comparable in the treatment of spastic angina.

[Vagal syncope in young adults: specificity of the tilt-table test]

OBJECTIVE

The head-up tilt test has been used for more than 10 years to reproduce vagal lipothymia. The criteria for a positive test and specificity are however still lacking.

METHOD

Thirty male volunteers, age 18 to 35 years, with no past history of lipothymia nor any signs of hypervagotonicity at physical examination, on fasting blood samples or on exercise tests with sudden interruption and Holter recording were selected for the study. Two head-up tilt tests at 60 degrees for 45 minutes were conducted, one with no presensitivisation and the other with a bolus of isoproterenol (2, 4, 6 and 8 micrograms) starting 30 minutes after the beginning of the test. Blood pressure was measured throughout the test.

RESULTS

The systolic blood pressure curves showed drops of more than 30 mmHg accompanied by spontaneously resolving clinical signs in 6 of the 30 subjects during the non-sensitized tests and in 14 out of 30 during the sensitized tests. A symptomatic drop in systolic blood pressure of more than 30 mmHg compared to the moment before the malaise accompanied by clinical signs which did not resolve within 1 minute and required returning to the supine position occurred in one volunteer during a non-sensibilized test. This same type of reaction was observed in 4 volunteers during sensitized tests, three times after an isoproterenol bolus.

CONCLUSION

Taking this later manifestation as the criteria for a positive head-up tilt test, the specificity of the non-sensitized and isoproterenol-sensitized tests in the young adult are 96.7 and 86.7% respectively. These findings must be considered with caution since there is no proof that these young men with no past history of hypervagotonicity but a positive head-up tilt test may be one day confronted with a situation generating a vagal reaction.

Assessment of aortic regurgitation severity by magnetic resonance imaging of the thoracic aorta

A new method of assessing the severity of aortic regurgitation severity by magnetic resonance imaging has been developed. Two groups were studied: 20 controls (age = 58 +/- 19 years) without valvular aortic disease, and 24 patients (age = 62 +/- 13 years) with chronic aortic insufficiency evaluated by magnetic resonance and aortic root cineangiography within 1 week of each other. A magnetic resonance sequence (TR = 35 ms/TE = 12 ms/flip angle = 20 degrees/magnet = 1.5 T) was acquired in a plane containing the thoracic aorta. A transverse saturation band 30 mm wide was positioned 30-40 mm above the aortic valve. Aortic insufficiency was graded; the importance of end-diastolic retrograde movement in the saturation band in the descending aorta was noted. Magnetic resonance was also compared to Doppler echocardiography in 20 patients. In the controls, we found that retrograde blood flow was absent (18/20) or mild (2/20). In contrast, the presence of marked retrograde movement in a saturation band across the thoracic aorta was always associated with severe aortic regurgitation (angiographic grade III or IV). This rapid method (imaging time less than 20 min) can be applied in most patients with aortic regurgitation and is likely to be helpful when echocardiography is not possible or gives inconclusive results.

[Does syndrome X exist?]

The syndrome X is an entity characterised by the association of chest pain on exercise and a positive exercise stress test in patients with normal coronary angiography. However, this diagnosis can only be admitted when all other causes of angina with normal coronary arteries have been excluded. They include angina secondary to coronary artery spasm and myocardial hypertrophy. A review of the literature based on 26 publications recensing 822 patients shows that these criteria are not always respected: a really positive exercise stress test is an inclusion criterion in only 13 studies and concerns only 313 patients (38.1%); myocardial hypertrophy and coronary spasm were formally excluded in only 278 (33.3%) and 228 patients (27.7%) respectively. Taking into consideration only the patients of these 26 series with a positive exercise stress test after exclusion of coronary spasm and myocardial hypertrophy, 143 (17.4%) may be considered to be due to syndrome X. Syndrome X is a real entity but its incidence is usually overestimated. It is appropriate to distinguish it from other conditions associating, though the exercise stress test is negative, chest pain on effort and the positivity of a test considered to be indicative of myocardial ischaemia.

[Evaluation of amlodipine in stable effort angina in office cardiologic practice]

A multicentre trial was undertaken in order to evaluate the therapeutic efficacy and ease of use of amlopidine in 1890 patients with stable effort angina. Involving prescribing conditions close to those of everyday practice, it revealed an improvement in angina symptomatology with one daily dose of amlopidine. After one month's treatment, 49.8% of patients were able to reduce or stop their use of fast-acting nitrites. After three months' treatment with amlopidine, 51% of patients had become asymptomatic. This study also revealed a decrease in the duration and severity of angina attacks. Safety/acceptability of amlopidine, assessed by clinical and laboratory parameters, was good, adverse events (22.7%), most often benign, improving or disappearing in more than half of all cases.

[Myocardial infarction after 80 years of age. Apropos of 157 cases]

The authors evaluated the features of myocardial infarctions in a population of 157 subjects aged 80 years or more out of a total of 1,610 patients admitted for myocardial infarction. It was a common condition in this age group (9.8% of the population) with a female predominance (61.8%), the main risk factor begin hypertension. A previous history of angina or infarctions, silent ischaemia, atypical electrocardiographic forms and anterior infarction were significantly more common. The outcome was characterised by a higher prevalence of haemodynamic complications with cardiac failure in 60% of cases and cardiogenic shock in 10% of cases. Atrial fibrillation was also more common though severe ventricular arrythmias were more infrequent. From the therapeutic point of view, 95.7% of octogenarians were given intravenous heparin but thrombolysis was undertaken in only one case. Coronary angiography, angioplasty and cardiac surgery were exceptional. Hospital mortality was 26.7%, seven times higher than that observed in patients under 65 years of age and nearly twice that of patients 65 to 79 years of age. After hospital admission, 45% of octogenarians were prescribed a calcium inhibitor, 37.2% a platelet anti-aggregant agent, 17.2% long-term oral anticoagulants and 1.9% a betablocker. These results show that myocardial infarction after 80 years of age is common, serious, but treated conventionally.

[Ambulatory venous thromboembolitic disease. Clinical, etiological and evolutive data]

OBJECTIVES

Venous stasis in bedridden patients is recognized as one of the risk factors for venous thromboembolism but the phenomena is known to occur in ambulatory subjects and another cause must be involved. We investigated a series of consecutive ambulatory patients with venous thromboembolism in order to distinguish the particular clinical manifestations and possible aetiologies.

METHODS

We compared a retrospective series of 120 consecutive patients with deep vein thromboembolism of the lower limbs and 127 patients with the same disease who had been bedridden at onset. In addition to the physical examination, the aetiological work-up included echography (n = 14), abdominal computed tomography (n = 38) and/or haemostasis studies (n = 61). Mean follow up was 23 +/- 13 months (range 1-45 months).

RESULTS

Family history of deep venous thromboembolism was found in 17 patients and recurrence was observed in 50 patients. Phlebitis was on the right in 52 cases, on the left in 47 and bilateral in 17. Proximal locations were more frequent (74%) and pulmonary embolism occurred in one-half of the patients (n = 58). A cause was identified in 61 cases (50.8%): cancer (n = 24, 17 known, 7 previously unknown), dyscrasia (n = 17, protein S or C deficiency (5), increased plasminogen activator inhibitor I (8), circulating anticoagulants (3), hypofibrinogen (1), idiopathic varicose veins (n = 7), pregnancy (n = 5), oral contraceptives (n = 4) and other causes (n = 4). No cause was identified in 59 patients. Pulmonary embolism led to death in 4 cases. Seven patients were lost to follow-up and anticoagulation therapy was taken by 79 (72%) then interrupted in the others 3 to 6 months later. Eighteen patients died, 14 due to the underlying disease, 2 from new cancers and 12 after recurrent thromboembolism.

CONCLUSION

Ambulatory venous embolism is as frequent as embolism in bedridden patients and the cause can be observed in 50% of the cases.

[Comparison of continuous and intermittent treatment with glyceryl trinitrate by the transdermal route in stable effort angina]

The anti-angina efficacy of the continuous (C) transdermal application of nitroglycerin may lessen or disappear over the course of time. Pharmacological tolerance, which is probably responsible, might be prevented by intermittent (I) application. However few studies have compared the C and I methods. The effects of transdermal patches containing 10 mg, applied for 24 hours/day and for 15 hours/day for one week were evaluated in twelve patients. Exercise tests were performed before and 4 hours after the initial application and after one week of each type of treatment prescribed in random order with a 7 day wash-out between each treatment phase. Plasma nitroglycerin concentrations were measured at the same time. Total work and ischemia and angina thresholds after 4 hours application all increased significantly in comparison with baseline values. All these values persisted after one week of I treatment. With C treatment they decreased though remained significantly above baseline values with the exception of angina thresholds. I treatment appeared significantly better than C treatment regarding ischemia threshold (3,974.7 kpm v. 3,037.5-p < 0.01). Plasma nitroglycerin levels were the same during each treatment phase. These results suggest that the anti-ischemic efficacy of transdermal patches persists after one week of treatment, though with superiority of intermittent treatment. Continuous treatment tends to induce pharmacodynamic tolerance since there was no difference in plasma nitroglycerin levels.

[False pseudoaneurysm of the left ventricle after myocardial infarction. Recognition by transesophageal echocardiography]

Left ventricular pseudo-false aneurysm is caused by a discrete rupture of the myocardial wall which remains circumscribed within the wall itself, realising a cavity joined to the left ventricle by a narrow neck. It is an extremely rare complication of myocardial infarction. Two cases diagnosed in vivo by left ventriculography are reported. Their diagnosis and precise locations were confirmed by transoesophageal echocardiography. In the first case, the pseudo-false aneurysm was situated in the interventricular septum and, in the second, in the antero-lateral wall. The natural history of asymptomatic pseudo-false aneurysms is unknown. The advanced age of the patients and the possibility of regular follow-up by transoesophageal echocardiography were the main reasons for surgical abstention in these particular cases.

[Contribution of myocardial biopsy and immunohistochemistry to the prognostic evaluation of cardiac amyloidosis]

The authors report four cases of cardiac amyloidosis, the diagnosis of which was confirmed by endomyocardial biopsy. They underline the value of immuno-histological studies with labelling of the biopsy fragments with anti-transthyretin and anti-light chain immunoglobulin antibodies. This approach provides a more precise typing of amyloidosis and a more accurate evaluation of the prognosis.

[Comparative study of the efficacy and tolerability of bepridil and diltiazem in unstable angina. 277 patients]

Bepridil has been used only rarely in unstable angina since its long half-life could imply a delayed action. A loading dose could deal with this disadvantage. In order to confirm this hypothesis, a randomised trial was undertaken involving a 5 day comparison of bepridil at the dose of 300 mg/day after a loading dose (900 mg on D1, 500 mg on D2 and D3) with diltiazem 360 mg/day in 277 patients: 210 men and 67 women, with a mean age of 62.1 +/- 9.5, suffering from unstable angina confirmed by an ECG during symptomatic events showing reversible ST depression. A continuous 72 hour ECG record was obtained in 82 patients. Because of 69 inclusion errors, only 208 patients provided evaluable data (110 with bepridil and 98 with diltiazem), including 55 with continuous ECGs. Mortality (4.5% bepridil v. 3.1% diltiazem) and premature treatment terminations for therapeutic inefficacy (4.5% bepridil v. 7.1% diltiazem), myocardial infarction (3.6% bepridil v. 3% diltiazem), adverse events (3.6% bepridil v. 3% diltiazem) or at the patient's request (0.9% bepridil) were similar between the 2 groups. Efficacy regarding angina was similar, with 18.2% recurrences with bepridil and 21.4% with diltiazem during the first 72 hours, persisting without any difference beyond 72 hours. Resulting treatment adjustments concerning nitrates were identical in the 2 groups. Among the 55 patients with an evaluable continuous ECG (27 bepridil and 28 diltiazem, NS), 18 had recurrent ischemic episodes (9 bepridil and 9 diltiazem), 72.2% of which were clinically silent. Their total number, total duration and maximum amplitude of ST depression were similar in the 2 groups.(ABSTRACT TRUNCATED AT 250 WORDS)

[Flecainide exercise induced left bundle branch with chest pain]

Ischaemia has been the suggested mechanism of simultaneous left bundle branch block and chest pain on effort with normal coronary angiography. This hypothesis is very controversial and was not the mechanism in the two new cases of this syndrome. The two patients in whom effort pain and left bundle branch block were observed had been treated for paroxysmal supraventricular tachycardia with flecaine. Withdrawal of the anti-arrhtymic resulted in the disappearance of this syndrome. In these cases, the ischaemic mechanism could be excluded without ambiguity. The flecaine was the only cause of rate-related LBBB by slowing conduction in the left bundle branch with no effects on coronary reserve. It would seem that LBBB alone was the cause of chest pain. The absence of coronary artery disease was confirmed in the first patient and the diagnosis was highly improbable in the second.

Cardioprotective effect of intracoronary nifedipine during percutaneous transluminal coronary angioplasty. A French double-blind cross-over multicentre study

The aim of this double-blind, placebo-controlled, cross-over study was to assess the cardioprotective effect of intracoronary nifedipine during percutaneous transluminal coronary angioplasty balloon occlusion. A balloon inflation without drug injection was initially made to ascertain that a shift of the ST segment (> or = 2 mm, 0.08 s after the J point) appeared (inclusion criterion). Two other balloon inflations were preceded by intracoronary injection of either 0.2 mg nifedipine or placebo, distal to the stenosis through the balloon catheter. The evaluation criteria were (1) time to ST segment shift, and (2) maximal amplitude of ST segment shift caused by balloon occlusion. Comparison of the data used an analysis of variance. Sixty-seven patients (mean age 54 +/- 8 years; 54 male, 13 female) were studied; 50 patients had 1-, 16 patients 2- and 1 patient 3-vessel disease. The dilated vessel was the left anterior descending coronary artery (n = 51), the right coronary artery (n = 12) and the left circumflex coronary artery (n = 4). Balloon inflation time was 100 +/- 31 s in the nifedipine group and 93 +/- 29 s in the placebo group. Five patients were excluded (procedure stopped after the first inflation in 1 and ST segment shift < 2 mm during the first inflation in 4). The time to 2-mm ST segment shift was longer in the nifedipine group than in the placebo group (62 +/- 40 s versus 51 +/- 40 s, P < 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

[Pulmonary perfusion tomoscintigraphy in pulmonary embolism. Preliminary study]

Tomoscintigraphy, a method developed over 10 years ago, is little used nowadays for the evaluation of suspected pulmonary embolism. The authors report the results of a preliminary study of 10 patients hospitalised for this condition. Tomoscintigraphy was normal in 2 cases and abnormal in 8 cases. Seven of these 8 patients underwent pulmonary angiography which confirmed the diagnosis of pulmonary embolism in 6 cases. The small number of patients, however, did not allow measurement of the sensitivity and specificity. Tomoscintigraphy, repeated at the 8th day and at the first month, provides an assessment of therapeutic efficacy. Some improvement is observed in all cases from the first control but the amount varies from one subject to another. At one month, 3 of the 6 patients undergoing control tomoscintigraphy had hypoperfusion sequellae. The simplicity of pulmonary tomoscintigraphy makes it a useful investigation for emergency diagnosis and follow-up pulmonary embolism.

[Vasculitis complicating treatment with streptokinase: delayed allergic reaction]

The authors report a case of vascular purpura occurring eleven days after the injection of streptokinase for a myocardial infarction. This adverse event falls within a context of hypersensitivity vasculitis (type III). In this particular case, imputation to the thrombolytic agent was established by the official method for the imputation of adverse or toxic effects of drugs. Routine renal function studies were normal. The outcome was satisfactory following rest only but the existence of a mixed cryoglobulinemia, responsible secondarily for cold-related distal ischemic symptomatology of the lower limbs led to the successful prescription of a short course of corticosteroids.

[Efficacy of intravenous milrinone in the treatment of acute congestive cardiac failure. Results of a French multicenter study]

The hemodynamic effects and safety of milrinone, a phosphodiesterase inhibitor, were studied in 57 patients in the acute phase of cardiac failure. The drug was given intravenously as an initial push dose of 50 micrograms/kg in 10 min followed by a 24 hour infusion at the dose of 0.5 micrograms/kg/min. Maximal response was obtained after 15 min and persisted throughout the infusion. Cardiac index rose by 40%, while pulmonary capillary pressure fell from 25 mmHg to 17 mmHg (-30%) by the fifth minute of treatment. Mean pulmonary artery pressure fell by 20% by the 15th minute. Systemic resistance decreased by 26% and pulmonary vascular resistance by 22%. All these variations were significant. Heart rate and systemic blood pressure remained stable. Study of three sub-groups: digoxin vs non-digoxin, sinus rhythm vs atrial fibrillation, and coronary patients vs non-coronary patients, revealed no significant difference. Safety of the drug was good, no extra-cardiac actions having required interruption of the infusion. Stoppage was made necessary by two instances of ventricular tachycardia. Improved hemodynamic effects and the good safety/acceptability of the drug indicate that milrinone is a treatment of choice in cardiac failure.

[My practice of thrombolysis in the acute phase of myocardial infarction in the light of extensive studies]

Hospital mortality due to myocardial infarction has decreased markedly since the 1970's. Intravenous thrombolysis is certainly one of the reasons for this decrease but its precise role cannot be defined. In practice, major therapeutic trials enable definition of the broad lines. It is nevertheless essential to combine our personal experience with their analysis. It is not yet possible at present to say which is the best thrombolytic. Use of the association streptokinase-rtPA has the advantages of both agents and the same risks at a lower cost than that of rtPA alone.

[Fungal thrombus of the right atrium on a central venous catheter. Apropos of a case]

The authors report the case of a 9 year old child in an intensive care unit after multiple trauma, presenting with a candida septicaemia and a central venous catheter. Echocardiography, performed because of the inefficacy of medical treatment, showed a right atrial thrombus. Surgical ablation was decided because of its extreme mobility and persisting infection, and resulted in cure of the patient.

Comparison of treatment with lisinopril versus enalapril for congestive heart failure

The effect of lisinopril 5-20 mg once daily or enalapril 5-20 mg once daily on exercise capacity, ventricular ectopic activity, and signs and symptoms of heart failure have been studied in 278 patients with mild-to-moderate (New York Heart Association [NYHA] classes II and III) heart failure in a randomized, double-blind, parallel-group study of 12 weeks' duration. Exercise duration was significantly increased by both angiotensin-converting enzyme (ACE) inhibitors after 6 and 12 weeks of treatment compared with their respective baseline values. There was a trend toward a greater increase in exercise duration on lisinopril after 12 weeks, although this did not reach statistical significance (p = 0.0748). There were no significant treatment differences with respect to the effect of the 2 drugs on ventricular ectopic counts, couplets, or nonsustained ventricular tachycardia. Both drugs were equally effective in improving NYHA grading and symptoms. Neither treatment had any significant effect on mean heart rate or mean blood pressures. Both treatments were equally well tolerated. The most commonly reported adverse events on both drugs were cough, dizziness, fall in blood pressure, vertigo, and myocardial infarction. The results of this study indicate that lisinopril 5-20 mg once daily is at least as effective and well tolerated as enalapril 5-20 mg once daily.

[Thrombolytic therapy of myocardial infarction: practical management]

Myocardial infarction (MI) is the result of acute coronary occlusion and the prognosis depends on the infarct size. In experimental studies, infarct size is reduced by early coronary reperfusion which may be obtained by intravenous thrombolytic therapy. This simple, rapid and widely used technique is the clinical treatment of choice. The diagnosis of MI must be confirmed by clinical and electrocardiographic findings. The clinical history is important because the value of reperfusion when started after the 6th hour after the onset of chest pain is questionable. However, it is often difficult to determine the beginning of MI when preceded by unstable angina. Contraindications to thrombolytic therapy must be carefully excluded irrespective of the thrombolytic agent because of the risk of haemorrhage. This must be weighed up against the risk of the MI itself. Therefore, age is not a systematic exclusion criterion. The choice of thrombolytic is based on the efficacy, mode of administration and cost. Heparin therapy at effective doses is associated in all cases to prevent reocclusion. Aspirin is given orally. The association of a calcium inhibitor or a betablocker may also be considered. Reperfusion and ischaemia may give rise to arrhythmias and haemodynamic changes which have to be rapidly corrected. Haemorrhagic complications during thrombolysis are treated according to the severity and time of onset by blood transfusion sometimes associated with a plasmin inhibitor. Reocclusion is an indication for emergency coronary angioplasty but in some cases repeat thrombolytic therapy may be beneficial. When the MI is extensive, rapid transfer to a cardiological centre with catheter facilities is advisable.(ABSTRACT TRUNCATED AT 250 WORDS)

[Lipid indicators of vascular risk. A cross-sectional study of a group of coronary patients, a group of subjects with normal coronary angiography and a control group]

During a transverse survey, 3 groups of men with the same weight and age were compared. Group I included 42 patients with coronary disease documented by coronarography, group 2 included 19 subjects with normal coronary angiograms, and group 3 included 27 healthy controls who had not undergone coronarography. Subjects presenting diabetes or any factor associated with secondary dyslipidemia or able to modify lipid levels were excluded from study. The following parameters were measured: total cholesterol (Chol), triglycerides (TG), HDL-cholesterol (HDL-C), LDL-cholesterol (LDL-C), apoprotein A1 (apoA1), apoprotein B (apoB), lipoprotein (a) or Lp(a), fibrinogen, insulinemia and plasminogen activator inhibitor activity (PAI). The levels of chol, LDL-C and ApoB were the same in the 3 groups. The levels of TG, HDL-C, apoA1 and the ApoA-1/APoB ratio were significantly different between groups 1 and 2, on the one hand, and groups 1 and 3, on the other hand. The levels of Lp(a) and insulin were similar in the 3 groups. Fibrinogen levels were slightly higher in group 1 than in group 3. There was no significant difference between groups 1 and 2 with regard to any of the parameters. Subjects with angiographically normal coronary arteries and subjects with documented coronary disease exhibited similar lipid abnormalities. In this study, TG, HDL-chol, apoA1 and the apoB ratio were better predictors of cardiovascular risk than Chol, LDL-C or apoB.

1H nuclear magnetic resonance and clinical studies of interaction of calcium antagonists and hypoglycemic sulfonylureas

The hypoglycemic effect of gliclazide is mainly due to its action on ATP stimulated K+ channels, but the calcium ionophoretic effect of this drug may also be involved in its physiological properties. Using 1H NMR we demonstrated the antiionophoretic effect of nifedipine and diltiazem. We attempted to verify whether this in vitro interaction also occurs in vivo. A clinical trial, was performed on patients treated concomitantly with gliclazide and nifedipine or diltiazem. Results showed that no in vivo interaction occurred. The discrepancy between in vivo and in vitro results may be explained by a too weak plasma concentration in the case of nifedipine and by a large plasma protein binding in the case of diltiazem.

[Late coronary reperfusion. A possible etiology of post-infarction angina]

Late recanalisation of the infarct Related Artery is possible and may cause post-infarction angina. This was observed in 7 male patients who had complete occlusions of an artery with collateral circulation in the immediate post-infarction period. After a symptom-free period of 17 months, angina recurred and repeat angiography showed recanalisation of the occluded artery with regression of the collateral circulation resulting in myocardial ischemia. Myocardial revascularisation was then required.

[Comparative study of effects of diltiazem, nifedipine and their combination on exercise stable angina]

Diltiazem and Nifedipine could be synergic. The aim of this study was to investigate the benefits of their association. Eighteen patients, 15 men and 3 women, average age 61 +/- 6 years, with stable angina on effort, were studied. Eight patients had single vessel disease and 10 patients had multivessel disease. The patients underwent a randomised double-blind trial with 4 successive treatment periods each lasting one week: placebo; 360 mg/day of Diltiazem; 60 mg/day of Nifedipine; 180 mg/day of Diltiazem with 30 mg/day of Nifedipine. The benefits were evaluated clinically, by exercise stress testing and with drug plasma concentrations at the end of each sequence. The results at the end of the 3 treatment periods were significantly better than with placebo. Diltiazem was significantly better than Nifedipine with respect to the development of angina during exercise testing (1 patient compared with 7 patients) and to maximum load (118.3 +/- 33.3 watts compared with 105.9 +/- 35.4 watts) (p less than 0.05). The association of the two drugs did not give better results than Diltiazem alone. Compared with placebo, the total duration of exercise testing and the duration of 1 mm ST depression were significantly longer during the 3 treatment sequences but there were no significant differences between each of them. Secondary effects were significantly more common with Nifedipine (7 patients) and with the drug association (9 patients) than with Diltiazem alone (3 patients) or placebo (1 patient). Plasma concentrations of Diltiazem were 328 +/- 35 ng/l with the 360 mg/day dosage and 137 +/- 52 ng/l with the 180 mg/day dosage.(ABSTRACT TRUNCATED AT 250 WORDS)