[Diagnosis and treatment of cardiac transthyretin amyloidosis. Innovative therapy with tafamidis.]

Cardiac amyloidosis is a rare and severe disease with worse prognosis than classic cardiac insufficiency. Transthyretin amyloïdosis is an underdiagnosed cause of amyloidosis. Technetium scintigraphy allows to confirm diagnosis of transthyretin amyloidosis with great specificity. A new hope is brought by tafamidis, a novel therapeutic option for this specific condition. This medication is the first one that proved a risk reduction in mortality among patients with cardiac amyloidosis in class NYHA I and II. In this article, we review across a clinical case the modalities for the diagnosis and treatment of transthyretin amyloidosis.

Chilblains

Idiopathic chilblain is a relatively common yet poorly recognized acrosyndrome. This literature review aims to better understand and draw attention to this disorder. Chilblain is a localized inflammation of the skin that occurs on exposure to cold but non-freezing wet weather. It usually resolves spontaneously. The etiology is uncertain, but vasospasm seems to play a role in this abnormal reaction to cold. Diagnosis is most often based on clinical presentation, but a skin biopsy can be useful in dubious cases. In histology, dermal edema and an inflammatory infiltrate are usually present. A distribution of the infiltrate particularly around the eccrine gland is typical. Systemic symptoms and underlying autoimmune disease should be screened. Avoiding cold and keeping extremities warm is the first recommendation for management, as well as smoking cessation. Calcium channel blockers (in particular nifedipine) seems to be the treatment that has been most evaluated in chilblains. However, their effectiveness is not confirmed by all studies. Topical betamethasone is often used but its effect has not been confirmed by randomized clinical trials. Other treatments, such as pentoxifylline, hydrochloroquine and topical nitroglycerin have shown positive effects only in a reduced number of patients. Acupuncture seems to bring a benefit.

Pretreatment with P2Y12 inhibitors and outcome in patients with ST-segment elevation myocardial infarction treated by primary percutaneous coronary intervention

AIMS

Preload with clopidogrel, ticagrelor, or prasugrel in the setting of ST-segment elevation myocardial infarction (STEMI) treated by primary percutaneous coronary intervention (PCI) is frequently applied. Limited data are available regarding the outcome impact of pretreatment with these drugs in the real world.

METHODS AND RESULTS

The outcome of 760 STEMI patients treated by primary PCI receiving clopidogrel, prasugrel, or ticagrelor (n = 269, 327, 164, respectively) was evaluated. Patients in the clopidogrel group were older, whereas those in the ticagrelor group had less hypertension but were more active smokers. Angiographic characteristics were comparable among the three groups. At 1 month, more events were observed in the clopidogrel group (11.1%) than in the ticagrelor and prasugrel groups (7.1 vs. 5.1%, P = 0.025), whereas the number of events in the ticagrelor and prasugrel groups did not differ. At 1 year, similar differences existed, mainly driven by a higher rate of death (19.5%, P = 0.008) or stent thrombosis (2 vs. 1.3% for ticagrelor, P = 0.132; vs. 0.3% for prasugrel, P = 0.07) in the clopidogrel group. In-hospital and 1-year bleeding rates were similar between groups.

CONCLUSION

In real-world practice, pretreatment with prasugrel or ticagrelor in ongoing STEMI treated by primary PCI seems to be a well tolerated alternative strategy compared with clopidogrel but provides superior benefit in terms of outcomes.

Duration of dual anti-platelet therapy - State of the art after the DAPT and PEGASUS-TIMI 54 trials

Dual anti-platelet therapy is prescribed in the setting of coronary heart disease for the prevention of stent thrombosis and acute thrombotic events. The optimal duration of dual anti-platelet therapy is still under debate as numerous trials have shown non-inferiority of a strategy of early cessation of one of the agents as compared to the standard practice whereas two larger trials have demonstrated benefit of prolonging dual anti-platelet therapy.

[Illustrated literature review of peripartum cardiomyopathy]

Peripartum cardiomyopathy is defined by the development of heart failure with left ventricular systolic dysfunction at the end of pregnancy or in the months following childbirth. Its diagnosis remains difficult due to lack of specificity. Its pathophysiology is still imperfectly understood, but involves both genetic and pregnancy related factors. From a therapeutic viewpoint, the recommendations of the European Society of Cardiology on heart failure are used, but the stage of pregnancy must be taken into account for the treatment choice. The chances of recovery are greater than in other non-ischemic cardiomyopathies. However, an early diagnosis remains crucial to increase the probability of recovery particularly with bromocriptine, which has shown positive results in recent years.

[Clinical case of the month. Purulent pericarditis in a patient with pulmonary sarcoidosis]

We report the case of a patient, suffering from pulmonary sarcoidosis, who developed a purulent pericarditis complicated with a cardiac tamponade. The widespread use of antibiotics has progressively reduced the number of purulent pericarditis. However, it remains a serious disease that has to be rapidly diagnosed to be treated timely. We will review the required tests for the diagnosis and the treatment of this pathology that leads to death otherwise. The link with pulmonary sardoidosis is uncertain.

[Prevention of restenosis and of cardiac events after coronary angioplasty in diabetics]

Various systemic pharmacological approaches have been evaluated to reduce the risk of restenosis and clinical complications after coronary angioplasty, with or without stent, a main objective in the high risk diabetic population. The aim of the present paper is to describe the effects of the main pharmacological classes on the risk of restenosis, the need for new revascularisation procedures and the incidence of major clinical events (MACE: death, myocardial infarction, revascularisation). We will analyse successively the role of antiplatelet agents, omega 3 fatty acids, statins, anti-inflammatory compounds, immunomodulators, anti-oxidants and inhibitors of the renin-angiotensin system. Whenever possible, we will focus our attention on the results obtained in the diabetic population.

[Incidence of restenosis and cardiac events after coronary angioplasty in diabetic patients: reduction by systemic pharmacological approaches]

Various systemic pharmacological approaches have been evaluated to reduce the risk of restenosis after coronary angioplasty, with or without stent, in the general population and in diabetic patients who are at increased risk for such complication. The aim of the present paper is to describe the effects of the main pharmacological classes on the risk of restenosis, the need for new revascularisation procedures and the incidence of major clinical events (MACE: death, myocardial infarction, revascularisation). We will analyse the role of antiplatelet agents, omega-3 fatty acids, statins, anti-inflammatory compounds, immunomodulators, anti-oxidants, glitazones and, finally, classical antidiabetic drugs such as metformin and insulin. Whenever possible, we will focus our attention on the results obtained in the diabetic population.

[Benefit-risk ratio of coronary drug-eluting stents: 2nd part: evaluation in the diabetic population]

The diabetic patient is at high risk of coronary heart disease. He/she can benefit of revascularisation procedures, even if he/she is exposed to a higher incidence of complications after a coronary artery bypass graft or a percutaneous transluminal coronary angioplasty. The use of drug-eluting stents--paclitaxel (PES) or sirolimus (SES)--dramatically reduces the risk of restenosis as compared to bare-metal stents; nevertheless, the rate of restenosis remains almost double in diabetic patients compared to that observed in non-diabetic subjects. However, the risk of (very) late thrombosis is higher with drug-eluting stents than with bare-metal stents, in the diabetic population as in the non-diabetic population. Altogether, among diabetic patients, the incidence of major cardiovascular events is significantly reduced with drug-eluting stents. This global clinical benefit essentially results from a diminution of revascularisation procedures rather than from a reduction of myocardial infarcts or cardiovascular deaths. Comparison between SES and PES gives discordant results. Indeed, while the loss of intra-stent lumen is more important with PES than with SES, PES are associated with a lower rate of major cardiovascular events than SES. Efficacious antiplatelet therapy in the long run is mandatory in all diabetic patients treated with drug-eluting stents.

[Benefit-risk ratio of coronary drug-eluting stents. 1st part: evaluation in the global population]

Coronary drug-eluting stents (DES) are increasingly used in interventional cardiology. Stents coated with pharmacological substances such as sirolimus or paclitaxel, capable of reducing endothelial proliferation, have been proposed to replace bare-metal stents (BMS) in order to reduce the risk of restenosis. The survey of the literature confirms a major and significant reduction in the risk of restenosis with both sirolimus and paclitaxel DES as compared to BMS in the global population. This effect leads to a diminished requirement for new revascularisation procedures. However, such DES may increase the risk of very late stent thrombosis, presumably due to a defect of endothelialisation, which requires long-term effective antiplatelet therapy. The impact on major clinical coronary events shows no significant difference in mortality between DES and BMS. However, the incidence of myocardial infarct may be, slightly but significantly, reduced with sirolimus DES. In a next paper, the same analysis will be specifically performed in the diabetic population, which is well known to be at high risk of coronary heart disease, but is also expected to particularly benefit from DES.

[Coronary drug-eluting stents in diabetic patients]

In diabetic patients, the use of drug-eluting stents (paclitaxel-PES or sirolimus-SES) reduces the risk of restenosis as compared to bare-metal stents. However, the risk of (very) late thrombosis is higher with drug-eluting stents than with bare-metal stents. All together, the incidence of major cardiovascular events is reduced with drug-eluting stents, mainly resulting from a diminution of revascularisation procedures rather than from a reduction in myocardial infarcts or cardiovascular deaths. Attempts to compare SES and PES gave discordant results in both randomised trials and registries. Efficacious antiplatelet therapy in the long run is mandatory in all diabetic patients treated with drug-eluting stents.