Apport de l’angioscanner pulmonaire dans l’évaluation de la gravité de l’embolie pulmonaire aiguë

Chest CT angiography has taken a major role in the management of patients with suspected pulmonary embolism. Meanwhile, it became necessary to determine the severity criteria at the time of diagnosis in order to properly assess the risk/benefit of treatment to consider. In recent years, pulmonary CT angiography has emerged as a useful tool for assessing the severity of acute lung embolism, based on morphological criteria. The two main approaches that were studied were the quantification of obstruction of pulmonary arterial bed and recognition of signs of right heart failure. The aim of our work is to define the morphological parameters in cardiovascular pulmonary CT angiography and to determine their value in the current clinical prognostic stratification of acute pulmonary embolism of, especially their correlation with the risk of developing signs of clinical severity at diagnosis and at 3 months of the occurrence of pulmonary embolism.     

Apport du peptide natriurétique de type B et de l’échocardiographie Doppler transthoracique au lit du patient dans le diagnostic d’insuffisance cardiaque aiguë

Acute heart failure is a common condition that leads to hospital admission, with important mortality and readmission rates. A prompt and accurate diagnosis of this condition by hospitalists is essential for an early and tailored medical management. The use of natriuretic peptide testing (BNP and NT-proBNP) through a two cut-point strategy is currently recommended as the first-line diagnostic complement to the initial clinical evaluation in the acute care setting. Transthoracic Doppler echocardiography is an other noninvasive method that can be used at bedside, especially in patients with intermediate, inconclusive natriuretic peptides levels. In this regard, left ventricular ejection fraction and several simple Doppler indexes (restrictive mitral filling pattern, spectral tissue Doppler E/e’ ratio), have been validated in the emergency diagnosis of acute heart failure. The aim of the present review is to overview the respective contribution of natriuretic peptides and Doppler echocardiography at bedside to the diagnosis of acute heart failure in the acute care setting.     

Actualités dans le syndrome de Susac

Susac syndrome is a rare disease affecting mainly young women, characterized by a microangiopathy limited to the cerebral, retinal, and cochlear vessels. Although the pathophysiology of Susac syndrome is not yet fully elucidated, recent advances favour a primitive vasculitis affecting the cerebral, retinal and cochlear small vessels. Susac syndrome must be recognized in the presence of the pathognomonic clinical triad associating: 1/subacute encephalopathy with unusual headache and pseudopsychiatric features associated with diffuse white matter, grey matter nuclei and specifically corpus callosum lesions on brain MRI; 2/eye involvement that may be pauci-symptomatic, with occlusions of the branches of the central artery of the retina at fundoscopy and arterial wall hyperfluorescence on fluorescein angiography; and 3/cochleo-vestibular damage with hearing loss predominating at low frequencies on the audiogram. Relapses are frequent during an active period lasting approximately 2 years. Eventually, the disease resolves but isolated retinal arterial wall hyperfluorescence without new occlusions may recur, which should not lead to treatment intensification. First-line treatment consists of a combination of anti-aggregants and high dose corticosteroids. In refractory patients or in case of relapse, immunomodulatory molecules such as intravenous immunoglobulins or immunosuppressive drugs such as mycophenolate mofetil, cyclophosphamide or rituximab should be started. Unfortunately, sequelae-mostly hearing loss- remain frequent in these young patients.     

Apport de l’échographie abdominale au cours de l’infection par le virus de l’immunodéficience humaine de l’adulte à Bangui (République centrafricaine)

Purpose

Describe the most frequent abdominal lesions in the ultrasound examination during the infection with HIV.

Patients and method

A transverse prospective study over a period of 12 months included 104 patients infected by the HIV and who presenting abdominal lesions.

Results Profits

The mean age of the patients was 36.2 years with extremes from 15 to 70 years and a sex-ratio of 1.3 in favour of the women. The age bracket from 30 to 39 years was the most affected touched. The abdominal lesions were dominated by: the lesions hepatobiliary in 41.2% of the cases, the deep adenopathies in 24.4%, deep lymph nodes in 24.4%, ascites in 14.4% and homogeneous or multinodulaire enlarged spleen in 11% of the cases. The renal, pancreatic and intestinal hurts were rare. About 30% of the patients had a rate of CD4 lower than 50 elements/mm³ and a little more than half (51%) was under for HIV.

Conclusion

Abdominal injury during the infection by the HIV are multiple. Abdominal echography allows to make an exhaustive work-up of the main lesions; any time, the results of this examination must be confronted with the biology and the anatomopathology for a diagnosis of certainty with the aim of better treatment.     

Anémie chez les patients avec syndrome coronarien aigu au centre hospitalier de Vichy

IntroductionObjectives were to determine the clinical, epidemiological and biological profile of the patients suffering from acute coronary syndrome and presenting the anaemia, the determinants of variation of the haemoglobin rate, and to estimate the impact of the anaemia on the prognosis of these patients.Patients and methodsRetrospective and observational study conducted in the cardiology department of Vichy Hospital in France. All patients with acute coronary syndrome admitted from 31 of October 2015 to 30 of April 2016 were selected. The patients were followed for 1 month. The anaemia was defined by: less than 13 g/dL in man and less than 12 g/L in woman (WHO definition). Biological markers were taken at the admission. Factors associated to the haemoglobin rate were analysed by multivariate linear regression and those associated to the mortality within 30 days were analysed by logistic regression.ResultsAmong 251 included patients, there were 180 males and 71 females with the average age of 67 years. 94 patients had ST elevation myocardial infarction (STEMI), 116 had Non ST myocardial infarction (NSTEMI) and 41 had unstable angina. Haemoglobin value was known in 238 patient's, among whom 44.1% were anaemic (105/238). The anaemia was more frequent in women. The tobacco was less frequent; High blood pressure, renal failure, malnutrition, subclinical atherosclerosis, lower limb arteritis and the inflammatory syndrome were more frequent in patients with anaemia. They presented more complications. The age (P = 0,003), the pulsed pressure (P = 0,007), LVEF (P = 0,005), the albumin (P = 0,010), Creatine kinase (CK) level (P = 0,048) and of CRP (P = 0,011), were linear factors of variations of the haemoglobin rate (R² = 0,955). Ten patients died during the follow-up. The multivariate analysis revealed the anaemia as independently associated with the mortality in 30 days (Odds Ratio 3,69; P = 0,02).ConclusionAnaemia is frequent in patients with an ACS, and it is associated with a particular clinical and biological profile. The patients with anaemia have a mortality rate in 30 days higher than the patients without anaemia.     

Étude et comparaison de la valeur pronostique de différents scores clinique,coronarographique et scintigraphique chez le patient coronarien stable après un syndrome coronarien aigu

IntroductionTo date, there is no consensus regarding the follow-up of asymptomatic coronary patients with an intermediate risk of events. Indeed, most of cardiovascular events (CVE) occur in asymptomatic patients, hence the clinician's interest in establishing risk stratification scores. In asymptomatic patient, the risk assessment after acute coronary syndrome (ACS) can currently be based on 3 types of score: clinical with, for example, the REACH score; angiographic with the residual SYNTAX score; imaging with different scintigraphic scores. These scores differ widely in terms of evaluation criteria and period of analysis. The aim of our study was therefore, in stable and asymptomatic coronary patients after ACS, to compare these different predictive scores; to establish that the combination of these scores makes it possible to optimize the risk assessment during the follow-up.MethodsOur retrospective study included 236 revascularized patients after ACS. Three different risk scores were collected: 1) the residual SYNTAX score, calculated at the time of revascularization; 2) the scintigraphic risk score described by Sharir et al., performed 3 to 12 months after the event and taking into account the extent of ischemia (SDS) and the poststress left ventricular ejection fraction (LVEF). Patients with LVEF < 50% and/or moderate to severe ischemic disease (SDS ≥ 2) were considered with an intermediate or high scintigraphic risk; 3) the REACH clinical score calculated on the day of the scintigraphic examination. After the myocardial scintigraphic exam, patients had a 1-year follow-up and CVE were recorded. Continuous data were analyzed either by Student's t-test or non-parametric Mann-Whitney test. The dichotomous data were compared either by the χ² test or by Fisher's exact test.ResultsForty-eight patients (20.1%) had a CVE during the 1-year follow-up. Thirty patients (13.8%) had a high residual SYNTAX score (≥ 8) without any correlation observed between the residual SYNTAX score and CVE (P = 0.359). 148 patients (57.7%) had a high REACH clinical score (≥ 11) with no significant correlation observed with CVE (P = 0.079). Lastly, 34 patients (14.4%) had an intermediate or high scintigraphic score, this imaging score being strongly correlated with a greater number of CVE (P < 0.001). Multivariate analysis revealed 3 independent factors associated with CVE: a scintigraphic score> 2 (OR [(95% CI): 5.530 [2.426–12.605] P < 0.001); Peripheral Arterial Obstructive Disease (PAOD) (OR [95% CI]: 8.531 [2.540–28.660] P < 0.001); diabetes (OR [95% CI]: 2.86 [1.262–6.517] P = 0,012).ConclusionThe combination of the scintigraphic score with two clinical factors, such as PAOD and diabetes, provides optimal prognostic value in the evaluation of asymptomatic and stable patients after ACS. Our study therefore highlights the importance of optimizing evaluation strategies in the follow-up of these patients who remain at risk of post-revascularization CVE.