EMC - Cardiologie-Angéiologie最新文献

The prevalence of cardiovascular diseases increases with age. Population aging induces an increasing number of revascularisation procedures (surgical or endovascular) among patients often presenting with multiple localisations of atherosclerotic disease. Since atherosclerosis is a diffuse process, a patient with an ischemic disease located in one territory has also, frequently, other asymptomatic localisations in other arterial territories. For example, we estimated that almost 50 to 70 % of late mortality after carotid surgery is mainly due to a coronary disease misdiagnosed at the time of pre operative assessment. Furthermore we know that among these patients 11 % have an associated aortic abdominal aneurysm when the actual incidence in the general population is 2 %. It is therefore of primary importance to consider this frequency of associated lesions in order to optimize the appropriate choice of imaging investigations.

Acrocyanosis is a permanent vascular acrosyndrome essentially revealed during winter. It is generally observed in young thin women, most of the time in a familial context. The typical form of primary acrocyanosis needs no complementary investigations. Clinical course is always favourable despite local infections and altered wound healing process.

The therapeutic utilisation of mineral waters is very ancient. The physiological effects of immersion are now well known. Immersion results in a significant increase of diuresis, cardiac output and haemodilution. The subsequent improved tissue perfusion and decreased oedema are beneficial, in case of occlusive lower limb arteriopathy and in case of chronic venous insufficiency. Fourteen French spas are specialized in the management of arteriopathies, and 11 other centres in that of chronic venous insufficiency. Thermatology is a complementary therapy; it should be combined with a kinesitherapy and the management of risk factors. During the thermal procedure, health education should be undertaken. Main indications are ischemic lower limb arteriopathies, and chronic venous insufficiency whichever the posture.

Thrombolytic therapy has been employed for 40 years, by systemic infusion, in the treatment of acute artery occlusions, and since 1971 by local infusion. Several randomised studies published during the 1990's have compared thrombolysis to surgery; they showed the benefits of the thrombolytic therapy, together with, however, the risks and potential complications. The use of thrombolysis combined with endovascular treatment of arterial lesions by recanalisation, thrombo-aspiration, angioplasty with or without endoprosthesis, has allowed defining new therapeutic strategies. The aim of the present chapter is to update one of our previous works by the identification of those new treatment modalities that have been used during the last decade, the presentation of the mechanism of action of standard thrombolytic drugs, streptokinase (SK) and urokinase (UK) utilised by systemic infusion, local fusion, and during per-operative procedures, and finally modern thrombolytic treatments from the plasminogen activator (tPA) to the staphylokinase. A European consensus has allowed to precise indications, contraindications and complications of such treatment (TASC). Recommendation # 59 concludes that there is no more indication for the systemic treatment of acute arterial occlusions with currently available thrombolytic drugs. The contraindications published in 1998 are actually widely known. Current indication remains local thrombolysis. The procedure duration, in addition to the associate risk of complications, is not always compatible with the emergency pattern of the revascularisation necessitated by some acute ischemias. Intra operative treatment is useful in by-pass occlusions. Despite insufficient published data, the combination of surgery and thrombolysis allows reducing both the dose and the duration of the procedure, which can be very important in severe cases of acute ischemia.

Pulmonary hypertension (PH) is generally defined by the presence of a resting pulmonary artery mean pressure (PAP) over 20 or 25 mmHg, whereas the pulmonary capillary wedge pressure is normal, which defines the precapillary feature of this PH. PH complicating respiratory disease, and particularly chronic obstructive pulmonary disease (COPD), is the most common of all forms of precapillary PH. It is not a severe PH bearing a poor prognosis and, in this regard, it markedly differs from idiopathic PH, but it may cause the occurrence of right heart failure. In most of the patients PAP, measured in a stable state of the disease, is mildly to moderately elevated (20-35 mmHg) but PH may worsen markedly during acute exacerbations, during exercise and during sleep. These sudden increases in right ventricular afterload can bring about the development of right heart failure. Alveolar hypoxia is by far the major cause of PH in COPD and, accordingly, the best treatment of hypoxic PH is long-term oxygen therapy during > 16-18 h/day. Long-term oxygen therapy improves or, at least, stabilizes pulmonary hypertension.

Intraventricular conduction disorders illustrate a slow or an interruption of impulse conduction in His bundle branches. Most commonly bundle branch blocks (BBB) are due to an anatomical lesion. In transient BBB, the specific underlying electrophysiological mechanism may be difficult to define.

Cardiac transplant remains the gold standard in the treatment of end-stage cardiac insufficiency. However, a great gap between the number of available grafts and the number of patients eligible to the waiting list for cardiac transplant leads, for some of them, to consider a surgical alternative in order to improve their clinical condition and delay as much as possible the transplant schedule. The goal is to treat surgically one or several of the lesions that influence the cardiac insufficiency. It may consist in valvular surgery, coronary surgery or a combination of both, ventricular remodelling or cardiomyoplasty. Coronary revascularisation results in spectacular improvement provided it concerns myocardial zones of which the viability has been demonstrated by thallium scintigraphy or stress echocardiography.