[Troponin I in massive acute pulmonary embolism: results of a prospective series].
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Acute Disease↗
Biomedical subjects
B Charbonnier
Publications and source records attributed to B Charbonnier.
Acute hemodynamic interaction of aspirin and ticlopidine with enalapril: results of a double-blind, randomized comparative trial.
BACKGROUND: Coprescription of aspirin and ACE inhibitors is frequent in heart failure caused by coronary artery disease. Negative interaction between aspirin and enalapril has been reported, presumably through inhibition by aspirin of ACE inhibitor-induced prostaglandin synthesis. Ticlopidine is a potent antiplatelet agent without interaction with prostaglandin synthesis. METHODS AND RESULTS: The objective of this study was to compare the influence of a coadministration of ticlopidine or aspirin on the hemodynamic effects of an ACE inhibitor (enalapril) in patients with chronic heart failure. Twenty patients with severe heart failure were enrolled in a double-blind comparative trial and allocated to ticlopidine (500 mg daily, 12 patients) or aspirin (325 mg daily, 8 patients). Hemodynamic evaluation was performed after 7 days of treatment, every hour for 4 hours after an oral administration of 10 mg of enalapril. Significant reductions in systemic vascular resistance were observed in the ticlopidine group, in contrast to no significant decrease in the aspirin group. A significant (P=0.03) time-by-treatment interaction indicated significant aspirin-enalapril drug interaction. Total pulmonary resistance decreased significantly in both groups, with no difference between patients assigned to aspirin or ticlopidine. CONCLUSIONS: Enalapril reduced systemic vascular resistance more effectively when given in combination with ticlopidine than with aspirin. In contrast, the reduction in total pulmonary resistance is similar when enalapril is administered in combination with aspirin or ticlopidine. Negative aspirin-enalapril interaction on prostaglandin synthesis presumably alters vasodilatation in systemic vessels, whereas prostaglandin-independent actions of ACE inhibition such as pulmonary arterial vasodilatation are maintained.
Adult↗
[Thrombolytics. Fundamentals and rules of use].
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Brain Ischemia↗
Randomized, double-blind study comparing saruplase with streptokinase therapy in acute myocardial infarction: the COMPASS Equivalence Trial. Comparison Trial of Saruplase and Streptokinase (COMASS) Investigators.
OBJECTIVES: This study sought to demonstrate the equivalence of saruplase and streptokinase in terms of 30-day mortality. BACKGROUND: The use of thrombolytic agents in the treatment of acute myocardial infarction is well established and has been shown to substantially reduce post-myocardial infarction mortality. METHODS: Three thousand eighty-nine patients with symptoms compatible with those of acute myocardial infarction for < 6 h entered the study at a total of 104 centers and were randomized to receive streptokinase (1.5-MU infusion over 60 min) or saruplase (20-mg bolus and 60-mg infusion over 60 min). In the saruplase group, a bolus of heparin (5,000 IU) was administered before saruplase, and a corresponding blinded double-dummy placebo bolus was administered before streptokinase. All patients received intravenous heparin infusions for > or = 24 h starting 30 min after the end of the thrombolytic infusions; the infusions were titrated to maintain an activated partial thromboplastin time at 1.5 to 2.5 times that of normal. RESULTS: Death of any cause up to 30 days after randomization occurred in 88 (5.7%) of 1,542 patients randomized to receive saruplase and 104 (6.7%) of 1,547 patients randomized to receive streptokinase (odds ratio 0.84, p < 0.01 for equivalence). Hemorrhagic strokes occurred more often in patients receiving saruplase (0.9% vs. 0.3%), whereas thromboembolic strokes were more prevalent in the streptokinase-treated patients (0.5% vs. 1.0%). The rate of bleeding was similar in the two treatment groups (10.4% vs. 10.9%). Hypotension and cardiogenic shock occurred less frequently in the saruplase group. Reinfarction rates were similar. CONCLUSIONS: Saruplase is a clinically safe and effective thrombolytic medication. This profile ranks saruplase favorably among the currently available thrombolytic agents.
Aged↗
A clinical trial of vena caval filters in the prevention of pulmonary embolism in patients with proximal deep-vein thrombosis. Prévention du Risque d'Embolie Pulmonaire par Interruption Cave Study Group.
BACKGROUND: The efficacy and safety of vena caval filters in the prevention of pulmonary embolism in patients with proximal deep-vein thrombosis is still a matter of debate. METHODS: Using a two-by-two factorial design, we randomly assigned 400 patients with proximal deep-vein thrombosis who were at risk for pulmonary embolism to receive a vena caval filter (200 patients) or no filter (200 patients), and to receive low-molecular-weight heparin (enoxaparin, 195 patients) or unfractionated heparin (205 patients). The rates of recurrent venous thromboembolism, death, and major bleeding were analyzed at day 12 and at two years. RESULTS: At day 12, two patients assigned to receive filters (1.1 percent), as compared with nine patients assigned to receive no filters (4.8 percent), had had symptomatic or asymptomatic pulmonary embolism (odds ratio, 0.22; 95 percent confidence interval, 0.05 to 0.90). At two years, 37 patients assigned to the filter group (20.8 percent), as compared with 21 patients assigned to the no-filter group (11.6 percent), had had recurrent deep-vein thrombosis (odds ratio, 1.87; 95 percent confidence interval, 1.10 to 3.20). There were no significant differences in mortality or the other outcomes. At day 12, three patients assigned to low-molecular-weight heparin (1.6 percent), as compared with eight patients assigned to unfractionated heparin (4.2 percent), had had symptomatic or asymptomatic pulmonary embolism (odds ratio, 0.38; 95 percent confidence interval, 0.10 to 1.38). CONCLUSIONS: In high-risk patients with proximal deep-vein thrombosis, the initial beneficial effect of vena caval filters for the prevention of pulmonary embolism was counterbalanced by an excess of recurrent deep-vein thrombosis, without any difference in mortality. Our data also confirmed that low-molecular-weight heparin was as effective and safe as unfractionated heparin for the prevention of pulmonary embolism.
Aged↗
Bolus Administration of Saruplase in Europe (BASE), a Pilot Study in Patients with Acute Myocardial Infarction.
To study the safety and efficacy of the thrombolytic agent saruplase as a bolus, the angiographic and clinical outcomes of three bolus regimens were investigated in a pilot study conducted in 192 patients with an acute myocardial infarction and were compared with the standard regimen. Fifty-two patients received a double bolus of 40 mg and 40 mg after 30 minutes, 51 patients a bolus of 80 mg, and 36 patients a bolus of 60 mg. Fifty-three patients received the standard regimen (a bolus of 20 mg and 60 mg IV infusion over 1 hour). At 60 minutes TIMI 2 and 3 flow were, respectively, 9.6% and 61.5% with the 40/40-mg bolus, 15.7% and 51.0% with the 80-mg bolus, 16.7% and 30.6% with the 60-mg bolus, and 7.5% and 54.7% with the standard 20/60-mg infusion. At 90 minutes TIMI 2 and 3 flow improved to 9.6% and 73.1%, 15.7% and 56.9%, 13.9% and 36.1%, and 5.7% and 71.7%, respectively. The primary endpoint, persistent patency (TIMI 2 + 3) at 24-45 hours, was seen in 69.2%, 64.7%, 44.4%, and 67.9% of patients who had no rescue PTCA, respectively. Inclusion in the 60-mg bolus group was prematurely stopped because of their low patency rates. The 40/40-mg bolus group had the highest mortality rate (13.5%), whereas the 60-mg bolus group had no deaths. Other adverse event rates were similar in the four groups. This clinical outcome is highly influenced by rescue PTCA of patients with insufficient TIMI flow. This pilot study indicates that in patients with an acute myocardial infarction, a double bolus of 40/40 mg resulted in the highest patency but also had the highest complication rate. The 80-mg single bolus is an attractive alternative for further evaluation because of its acceptable patency and event profile, and its easy form of administration.
Journal Article↗
Rapid haemodynamic improvement following saruplase in recent massive pulmonary embolism.
In a single centre pilot study, saruplase (20 mg bolus plus 60 mg infusion over 1 h) was administered to twenty patients with an angiographically documented recent massive pulmonary embolism: Miller index of at least 20 and mean pulmonary artery pressure of at least 20 mmHg. The lytic ability of saruplase to cause normalization of haemodynamic parameters over the first 12 h and reperfusion of pulmonary arteries at 24 h was assessed. A decrease of 25 +/- 10% in total pulmonary resistance was evident at 30 min. Haemodynamic parameters continued to improve with total pulmonary resistance decreasing by 29 +/- 8% and 40 +/- 11% at 1 and 12 h respectively. Relative improvement in Miller index 24 +/- 6 h after saruplase treatment was 38 +/- 9%. Two patients suffered recurrent pulmonary embolism, two severe bleeding events were observed. One patient died following a haemorrhagic stroke.
Adolescent↗
[Comparative efficacy and risks of low molecular weight heparins and thrombolysis in massive pulmonary embolism without cardiogenic shock].
The aim of this retrospective study was to assess pulmonary reperfusion by scintigraphy, the risks of recurrent embolism and of bleeding complications at the 7th day and 3rd month in 2 groups of patients admitted to hospital for massive pulmonary embolism without cardiogenic shock treated by intravenous thrombolysis (Group I) and by subcutaneous low molecular weight heparin (Group II) paired by Miller's index. The basal characteristics of the two groups, each comprising 31 patients, were comparable with respect to the severity of the pulmonary embolism with an average global scintigraphic defect of 40.6 +/- 13.5% in Group I and 39 +/- 13.7% in Group II. The scintigraphic changes at the 7th day were comparable with a relative improvement of 55 and 51% respectively and at 3 months of 74% in both groups. There was no significant difference in terms of recurrence of embolism (3 versus 0% at the 7th day and 3% in each group at 3 months) or of bleeding complications (13 and 10% at the 7th day and 10 and 6% at 3 months respectively). Low molecular weight heparin seems to be as effective as intravenous thrombolysis for the treatment of massive pulmonary embolism without shock. This result requires confirmation by a large scale prospective randomised trial.
Aged↗
[Incidental discovery of a giant myxoma].
The authors report a case of very large myxoma of the left atrium, original in terms of its mode of discovery, its very calcified appearance, in a totally asymptomatic elderly patient. A complete ultrasound assessment, catheterization, and coronary angiography allowed assessment of the morphology, topography, blood supply and cardiac repercussions of this tumour. Myxoma of the left auricle is the commonest cardiac tumour, with multiple clinical features and presentations. This benign tumour arises from embryonic vestigial remains, usually in the fossa ovale. The present case is original by its unusual mode of discovery in a totally asymptomatic patient.
Angiocardiography↗
[Cardiac metastasis of chondrosarcoma: a case report].
Chondrosarcoma is a primary malignant bone tumour which only exceptionally metastasises to the heart. We report a case of chondrosarcoma with left intracavitary cardiac metastasis discovered following abnormal cardiac auscultation. To our knowledge, only 21 cases have been described in the literature. A lesion of the right atrium is the most frequent event. The major risk of these tumours is their emboligenic properties: pulmonary embolism for metastases of the right heart, systemic embolism for metastases of the left heart. Echocardiography establishes the diagnosis by specifying the site and extent of the tumour. CT scan allows local assessment of the lesions. The course is fatal, although surgery has been able to increase survival of patients with isolated cardiac mestastases.
Aged↗
A comparison of low-molecular-weight heparin with unfractionated heparin for acute pulmonary embolism. The THESEE Study Group. Tinzaparine ou Heparine Standard: Evaluations dans l'Embolie Pulmonaire.
BACKGROUND: Low-molecular-weight heparin appears to be at least as effective and safe as standard, unfractionated heparin for the treatment of deep-vein thrombosis, but only limited data are available on the use of low-molecular-weight heparin to treat acute symptomatic pulmonary embolism. METHODS: We randomly assigned 612 patients with symptomatic pulmonary embolism who did not require thrombolytic therapy or embolectomy to either subcutaneous low-molecular-weight heparin (tinzaparin) given once daily in a fixed dose or adjusted-dose, intravenous unfractionated heparin. Oral anticoagulant therapy was begun between the first and the third day and was given for at least three months. We compared the treatments at day 8 and day 90 with respect to a combined end point of recurrent thromboembolism, major bleeding, and death. RESULTS: In the first eight days of treatment, 9 of 308 patients assigned to receive unfractionated heparin (2.9 percent) reached at least one of the end points, as compared,with 9 of 304 patients assigned to low-molecular-weight heparin (3.0 percent; absolute difference, 0.1 percentage point; 95 percent confidence interval, -2.7 to 2.6). By day 90, 22 patients assigned to unfractionated heparin (7.1 percent) and 18 patients assigned to low-molecular-weight heparin (5.9 percent) had reached at least one end point (P=0.54; absolute difference, 1.2 percentage points; 95 percent confidence interval, -2.7 to 5.1). The risk of major bleeding was similar in the two treatment groups throughout the study. CONCLUSIONS: Under the conditions of this study, initial subcutaneous therapy with the low-molecular-weight heparin tinzaparin appeared to be as effective and safe as intravenous unfractionated heparin in patients with acute pulmonary embolism.
Acute Disease↗
Comparison of saruplase and alteplase in acute myocardial infarction. SESAM Study Group. The Study in Europe with Saruplase and Alteplase in Myocardial Infarction.
Four hundred seventy-three patients with acute myocardial infarction (AMI) were treated with either saruplase (80 mg/hour, n = 236) or alteplase (100 mg every 3 hours, n = 237). Comedication included heparin and acetylsalicylic acid. Angiography was performed at 45 and 60 minutes after the start of thrombolytic therapy. When flow was insufficient, angiography was repeated at 90 minutes. Coronary angioplasty was then performed if Thrombolysis In Myocardial Infarction (TIMI) trial 0 to 1 flow was seen. Control angiography was at 24 to 40 hours. Baseline characteristics were similar. Angiography showed comparable and remarkably high early patency rates (TIMI 2 or 3 flow) in both treatment groups: at 45 minutes, 74.6% versus 68.9% (p = 0.22); and at 60 minutes 79.9% versus 75.3% (p = 0.26). Patency rates at 90 minutes before additional interventions were also comparable (79.9% and 81.4%). Angiographic reocclusion rates were not significantly different: 1.2% versus 2.4% (p = 0.68). After rescue angioplasty, angiographic reocclusion rates of 22.0% and 15.0% were observed. Safety data were similar for both groups. Thus, (1) early patency rates were high for saruplase and alteplase treatment, (2) reocclusion rates for both drugs were remarkably low, and (3) complication rates were similar. Thus, saruplase seems to be as safe and effective as alteplase.
Aged↗
Free-floating thrombus and embolic risk in patients with angiographically confirmed proximal deep venous thrombosis. A prospective study.
BACKGROUND: A free-floating thrombus (FFT) is often considered to be a risk factor for pulmonary embolism (PE), despite adequate anticoagulation therapy, in patients with proximal deep venous thrombosis. METHODS: Ninety-five patients underwent prospective assessment according to the presence (FFT group [n = 62]) or absence (occlusive thrombus group [n = 28]) of an FFT. On day 1, color venous duplex scanning, venography (reference method), perfusion lung scanning, and, if results of the lung scan were abnormal, pulmonary angiography were performed. On day 10 (range, days 9-11), the lung scan was repeated, as well as pulmonary angiography if the lung scan demonstrated impairment. A 3-month clinical follow-up visit was scheduled. Five patients were retrospectively excluded from analysis for uncertain diagnosis of FFT. Patients were treated with intravenous unfractionated heparin sodium adjusted for activated partial thromboplastin time (n = 1) or subcutaneous low-molecular-weight heparin (n = 89) (nadroparin calcium, 225 Institut Choay factor Xa inhibitory units per kilogram for 12 hours). Warfarin sodium therapy was initiated on day 3 (range, days 2-4). RESULTS: Both groups were well-matched according to age, sex, risk factors, and delay from onset of symptoms to treatment. Positive and negative predictive values of color venous duplex scanning for the diagnosis of an FFT were 91% and 55%, respectively. On admission, PE prevalence was 64% in the FFT group (40 of 62 patients) and 50% in the occlusive thrombus group (14 of 28 patients) (P = .19). Two patients were excluded on follow-up analysis (range, days 9-11) for preventive vena cava filtering (due to major bleeding in 1 and cholecystectomy in the other); the recurrent rate of PE was 3.3% in the FFT group (2 of 61 patients) and 3.7% in the occlusive thrombus group (1 of 27 patients). No symptomatic recurrent PE occurred between day 10 (range, days 9-11) and 3 months. Four patients died of evolutive neoplasm after hospital discharge. CONCLUSIONS: No higher risk for PE was observed in patients with free-floating proximal deep venous thrombosis; anticoagulant therapy should prevent recurrent PE in such patients.
Aged↗
Pseudo-homozygous activated protein C resistance due to coinheritance of heterozygous factor V Leiden mutation and type I factor V deficiency. Variable expression when analyzed by different activated protein C resistance functional assays.
The laboratory diagnosis of activated protein C (APC) resistance is based on a weak anticoagulant response to APC using a chronometric procedure confirmed in almost all cases by molecular diagnosis of the FV Leiden mutation. A recently-developed Xa-based assay (Accelerimat, Biomerieux) was compared with two different activated partial thromboplastin time (APTT)-based procedures (Coatest APC resistance and Modified Coatest, Chromogenix) in 115 patients with a personal or familial history of thrombotic disease, or both, being studied for the FV Leiden mutation. Our results confirmed the improvement in specificity for the FV Leiden mutation when the APTT-based assay was performed after dilution of samples in FV-deficient plasma (Modified Coatest). However, five patients who were heterozygous for the FV Leiden mutation appeared to be homozygous when tested by both APTT-based assays. These patients, belonging to three different families, had a FV type I deficiency with FV plasma levels between 43 and 64%. In contrast, the Xa-based method was not influenced by the decrease in plasma FV levels. Thus, this procedure is more specific than APTT-based assays to predict the genotype status of the FV Leiden mutation.
Adolescent↗
[Implantation of coronary stent during the acute phase of myocardial infarction for treatment of dissection or partial result after angioplasty. Immediate results and angiographic follow-up].
Between December 1991 and November 1994, a Palmaz-Schatz stent was implanted in 9 patients aged 57 +/- 14 years during the acute phase of myocardial infarction after primary angioplasty in 7 cases and salvage angioplasty in 2 cases after an interval of 175 mm +/- 62 mn from the onset of infarction, because of threatening dissection (N = 8) or a partial result (N = 1). The success rate of implantation was 100% with residual stenosis (DCI Philips system) measured at 16 +/- 8% (5 to 28%). Anticoagulant treatment comprised heparin, coumadin and aspirin in two cases, and, in the following 7 cases, low molecular weight heparin, ticlopidine and aspirin. There was one death due to cardiogenic shock on the third day despite intraaortic balloon pumping. One patient was operated for a femoral aneurysm. A prophylactic bypass procedure was performed as a semi-emergency in a stable patient. At systematic angiographic control, the residual stenosis was measured at 19 +/- 14% (10 to 43%) without reocclusion. There was no recurrence of ischaemia. The authors conclude that the encouraging results of this short series suggest that despite the highly thrombogenic situation of acute myocardial infarction and despite the context of emergency implantation of a stent. Palmaz-Schatz stent implantation gives good immediate and long-term results with respect to reocclusion and stenosis.
Adult↗
[Fraxiparin and prevention of left ventricular thrombosis in non-thrombolyzed myocardial infarction. FRATIV Study].
The aim of this trial, undertaken with the participation of 13 centres, was to establish the minimal effective dosage of nadroparin (Fraxiparin) for the prevention of left ventricular mural thrombosis in acute anterior myocardial infarction which was not treated by thrombolysis. Patients had myocardial infarcts less than 3 days old with no previous anticoagulant therapy or for at least 24 hours without mural thrombus in the left ventricle on baseline echocardiography. The protocol consisted of an intravenous bolus of nadroparin of 3.075 IU (0.3 mL) followed by daily subcutaneous injection of either 60 IU/kg/day (group 1) or 100 IU/kg/day (group 2) for 10 days, associated with aspirin. The criterion of judgement was the number of left ventricular thrombi observed in each group: the secondary criteria were the number of deaths, haemorrhagic and thromboembolic events. One hundred and forty-eight patients were included (group 1: 79 patients, group 2: 69 patients). One hundred and nineteen were evaluated for the principal criterion including 12 were considered as failures: 9 deaths (3 in group 1 and 6 in group 2) and 1 recurrent myocardial infarction, 1 ischaemic cerebrovascular attack and 1 atrial fibrillation in group 1. One hundred and seven patients were controlled at Day 0 and Day 10. The incidence of left ventricular mural thrombi was identical in the two groups: 7/56 in group 1 (12.5%) and 9/51 in group 2 (17.6%) (NS). Analysis of secondary criteria showed no difference between the two groups: there were no major haemorrhagic complications. The authors conclude that there is no difference in efficacy between the two dosages of nadroparin. However, the incidence of left ventricular thrombi was globally low in this study (11.6%).
Aged↗
[Paradoxical embolism and thrombosis trapped in the foramen ovale. Role of transesophageal echocardiography].
The authors report a case of paradoxical embolism presenting with syncope and a transient cerebrovascular accident. A large thrombus was observed entrapped in the foramen ovale during transthoracic echocardiography and confirmed at transoesophageal echocardiography. Despite the recent cerebrovascular event surgery was successfully performed. This clinical situation, and a review of the literature illustrate the diagnostic value of transoesophageal echocardiography, the finding of an intra-atrial thrombus being a possible surgical indication when the clinical context is favourable.
Echocardiography, Transesophageal↗
[Coronary embolism disclosing thrombosis on a Medtronic-Hall aortic valve prosthesis in aortic position].
A 32 year-old-man admitted to hospital on the third day of myocardial infarction, three months after aortic valve replacement with a mechanical Medtronic-Hall prosthesis. The embolic character of the disease was evident on coronary angiography which showed a large thrombus in the left main coronary artery. The thrombosis of the valve prosthesis was not detected by non-invasive investigations but at aortography, confirmed at surgery. Thrombolysis with rt-PA did not dissolve the clot and reoperation was necessary (valve replacement with aorto-coronary bypass grafting).
Adult↗