Consensus statement on the care of the hyperglycaemic/diabetic patient during and in the immediate follow-up of acute coronary syndrome.

The Diabetes and Cardiovascular Disease study group of the Société francophone du diabète (SFD, French Society of Diabetes) in collaboration with the Société française de cardiologie (SFC, French Society of Cardiology) have devised a consensus statement on the care of the hyperglycaemic/diabetic patient during and in the immediate follow-up of acute coronary syndrome (ACS); in particular, it includes the different phases of ACS [the intensive care unit (ICU) period, the post-ICU period and the short-term follow-up period after discharge, including cardiac rehabilitation] and also embraces all of the various diagnostic and therapeutic issues with a view to optimizing the collaboration between cardiologists and diabetologists. As regards diagnosis, subjects with HbA(1c) greater or equal to 6.5% on admission may be considered diabetic while, in those with no known diabetes and HbA(1c) less than 6.5%, it is recommended that an OGTT be performed 7 to 28 days after ACS. During hospitalization in the ICU, continuous insulin treatment should be initiated in all patients when admission blood glucose levels are greater or equal to 180 mg/dL (10.0 mmol/L) and, in those with previously known diabetes, when preprandial glucose levels are greater or equal to 140 mg/dL (7.77 mmol/L) during follow-up. The recommended blood glucose target is 140-180 mg/dL (7.7-10 mmol/L) for most patients. Following the ICU period, insulin treatment is not mandatory for every patient, and other antidiabetic treatments may be considered, with the choice of optimal treatment depending on the metabolic profile of the patient. Patients should be referred to a diabetologist before discharge from hospital in cases of unknown diabetes diagnosed during ACS hospitalization, of HbA(1c) greater or equal to 8% at the time of admission, or newly introduced insulin therapy or severe/repeated hypoglycaemia. Referral to a diabetologist after hospital discharge is recommended if diabetes is diagnosed by the OGTT, or during cardiac rehabilitation in cases of uncontrolled diabetes (HbA(1c) ≥ 8%) or severe/repeated hypoglycaemia.

Consensus statement on the care of the hyperglycaemic/diabetic patient during and in the immediate follow-up of acute coronary syndrome.

The Diabetes and Cardiovascular Disease study group of the Société francophone du diabète (SFD, French Society of Diabetes) in collaboration with the Société française de cardiologie (SFC, French Society of Cardiology) have devised a consensus statement on the care of the hyperglycaemic/diabetic patient during and in the immediate follow-up of acute coronary syndrome (ACS); in particular, it includes the different phases of ACS [the intensive care unit (ICU) period, the post-ICU period and the short-term follow-up period after discharge, including cardiac rehabilitation] and also embraces all of the various diagnostic and therapeutic issues with a view to optimalizing the collaboration between cardiologists and diabetologists. As regards diagnosis, subjects with HbA(1c) greater or equal to 6.5% on admission may be considered diabetic while, in those with no known diabetes and HbA(1c) less than 6.5%, it is recommended that an OGTT be performed 7 to 28days after ACS. During hospitalization in the ICU, continuous insulin treatment should be initiated in all patients when admission blood glucose levels are greater or equal to 180mg/dL (10.0mmol/L) and, in those with previously known diabetes, when preprandial glucose levels are greater or equal to 140mg/dL (7.77mmol/L) during follow-up. The recommended blood glucose target is 140-180mg/dL (7.7-10mmol/L) for most patients. Following the ICU period, insulin treatment is not mandatory for every patient, and other antidiabetic treatments may be considered, with the choice of optimal treatment depending on the metabolic profile of the patient. Patients should be referred to a diabetologist before discharge from hospital in cases of unknown diabetes diagnosed during ACS hospitalization, of HbA(1c) greater or equal to 8% at the time of admission, or newly introduced insulin therapy or severe/repeated hypoglycaemia. Referral to a diabetologist after hospital discharge is recommended if diabetes is diagnosed by the OGTT, or during cardiac rehabilitation in cases of uncontrolled diabetes (HbA(1c)≥8%) or severe/repeated hypoglycaemia.

Heart rate variability to assess ventilatory thresholds: reliable in cardiac disease?

BACKGROUND: The first (VT1) and second (VT2) ventilatory thresholds are landmarks to tailor exercise rehabilitation in coronary artery disease (CAD) or chronic heart failure (CHF). Methods allowing VT1 and VT2 determination based on heart rate variability (HRV) have been proposed but not yet evaluated in these patients. DESIGN: To determine the heart rate (HR) associated with VT1 and VT2 by three methods of HRV analyses. METHODS: Fourteen CHF and 24 CAD patients performed an exercise test on a cycle ergometer (10 -W every minute until exhaustion). VT1 and VT2 were determined with the 'respiratory equivalent' method. HR at VT1 was determined with the standard deviation (SD) of R⊟R intervals (VT(SD)) and of the instantaneous beat-to-beat variability of the Poincaré plot method (VT(Poincaré)). HR at VT1 and VT2 was determined through a time-varying HRV analysis method (VT(TV1) and VT(TV2), respectively). RESULTS: HR at VT(SD) was significantly higher than HR at VT1. No significant differences were observed between HR at VT(Poincaré), VT(TV1), and at VT1, nor between HR at VT(TV2) and VT2. HR at VT(SD), VT(Poincaré), and VT1 were significantly correlated, but with a low r (2) value and a large mean HR difference. With the time-varying method, the mean HR difference was lower than 5% and the correlation coefficients were higher (especially for VT(TV2)). CONCLUSIONS: SD and Poincaré plot methods lead to substantial inaccuracy in HR estimates. The time-varying HRV analysis led to strong correlation coefficients and low limits of agreement. Therefore, this method may be a promising, low-cost tool for non-invasive assessment of the ventilatory thresholds in cardiac disease.

Exercise rehabilitation restores physiological cardiovascular responses to short-term head-out water immersion in patients with chronic heart failure.

PURPOSE: Rehabilitation programs increasingly involve immersed exercising, including inpatients suffering from severe cardiovascular diseases such as coronary artery disease (CAD) or chronic heart failure (CHF). The hemodynamic responses to short-term head-out water immersion are not well defined in these diseases. This study was aimed at evaluating (1) the cardiac and peripheral hemodynamic responses to short-term head-out water immersion in patients with CHF (n = 12) and CAD (n = 12) and (2) the effect of a rehabilitation program on these responses. METHODS: Wrist arterial tonometry was performed in the upright posture before and during immersion (1.30-m depth) once before and once after a 3-week rehabilitation program including gymnic water exercises. RESULTS: In patients with CAD, water immersion triggered a significant increase in stroke volume, cardiac output, and pulse pressure and a significant decrease in pulse rate, diastolic blood pressure, and systemic vascular resistances, both before and after the rehabilitation program. In patients with CHF, no significant immersion-linked changes in cardiovascular variables were observed before rehabilitation. However, after completion of the rehabilitation program, it was found that water immersion caused significant increases in stroke volume, cardiac output, and pulse pressure. CONCLUSION: In patients with CHF, this 3-week rehabilitation program restored the usual central responses to head-out water immersion (increase in stroke volume and cardiac output). In both patients with CHF and CAD, acute water immersion did not change arterial compliance.

Influence of carvedilol on the benefits of physical training in patients with moderate chronic heart failure.

AIMS: To evaluate prospectively the impact of carvedilol on a short-term physical training program in stable patients with moderate chronic heart failure (CHF), and to analyze parameters predictive of improvement after training. METHODS AND RESULTS: Thirty-eight patients with CHF were referred for cardiac rehabilitation. Etiology was ischemic in 26 patients, dilated in 12 patients and left ventricular ejection fraction was <35%. Patients were classified into three groups: group 1 (n=14)=ACE inhibitors, diuretics and digitalis; group 2 (n=11)=idem group 1+cardioselective beta-blocker; group 3 (n=13)=idem group 1+carvedilol. Exercise tests with VO2 measurement were performed before and after a 4-week exercise training program. Patients with carvedilol experienced a 16.6% increase in peak VO2 which was similar to the 13.9% increase in the group with cardioselective beta-blocker and to the 18.5% in the group without beta-blocker. Moreover non-ischemic etiology of CHF was the only parameter predictive of improvement after training (P=0.02). CONCLUSION: Addition of carvedilol did not alter benefits of a short-term physical training program in patients with moderate CHF. No baseline characteristic except for etiology of CHF was predictive of a response to training.

[Prognosis and risk evaluation of postoperative coronary patients (PERISCOP). Methodology and study population characteristics]. / Pronostic et évaluation du risque chez le coronarien opéré (PERISCOP). Méthodologie et caractéristiques de la population incluse.

The aim of the PERISCOP study was to evaluate the predictive value of cardiological investigations performed after recent coronary bypass surgery with regards to cardiac event and mortality at one year. The treatment of lipid abnormalities was also analysed. This first article describes the methodology and patient characteristics at inclusion. This prospective national multicenter trial included 2065 patients (86% men) with an average age of 63.1 +/- 9.9 years. The number of diseased vessels was 2.6 +/- 0.6. Preoperative left ventricular function was normal (ejection fraction 60 +/- 13%). Revascularisation was complete in 73% of cases (22% of arterial grafts). The cardiological investigations were performed at Day 20 +/- 10 after surgery. The duration of exercise on stress testing was 429 +/- 170 seconds. It was positive or doubtful in 9% of cases. Ventricular arrhythmias were observed in 6.5% of cases. The blood pressure response was abnormal in 6% of cases. Holter monitoring showed a median number of ventricular extrasystoles over 24 hours of 44. Three per cent of patients had one episode of ventricular tachycardia and 7% had ischaemic episodes. The echocardiographic index of segmental contractility was on average 1.75 (ejection fraction: 52.6%). The lipid analysis performed at one month, under lipid therapy in 34% of cases, showed a total cholesterol level at 1.91 +/- 0.10 g/l, an LDL-cholesterol of 1.27 +/- 0.08 g/l. The therapeutic target (LDL-cholesterol < 1 g/l) was attained in 46% of cases with treatment and in 18% of cases without treatment.

[Return to work after cardiovascular rehabilitation in 128 coronary patients followed for 7 years. Results and medico-economic analysis]. / Réinsertion professionnelle après réadaptation cardiovasculaire chez 128 patients coronariens suivis pendant 7 ans. Résultats et réflexion médico-économique.

This was a prospective study of the modalities of return to work in a male population of 128 patients (mean age 48.9 years)) admitted for cardiovascular rehabilitation after acute infarction or coronary bypass surgery and followed up for 7 years. At one year, 78.9% of the population had returned to work (average delay 126 +/- 97 days), usually to the same job (66.3%) after adaptation (25.8%) or professional reconversion (7.9%). After 3 and 7 years follow-up, the active population was 62.5% and 40.7% respectively and the main reason for definite stopping work was retirement (63%). Temporary stoppages were short (4.5 days and 8.2 days per patient per year at 3 and 7 years respectively), illustrating the good quality of professional rehabilitation. The factors influencing return to work during the first age were young age (47.5 versus 52.7 years) and negative exercise stress tests (83% versus 59% in cases of positive tests, p < 0.05). This study and a review of the literature were used to undertake a medico-economic analysis which showed decreased economic consequences in patients referred for rehabilitation: over 5 years in a group of 100 patients, an economy of 5,818 KF after myocardial infarction or 2,677 KF after coronary bypass surgery was demonstrated. The reasons for these economies were the reduced direct (hospital admissions) and indirect costs (social security reimbursement for off-work and invalidity pensions). Those favourable results underline the value of a consultation of professional aptitude in all programmes of cardiovascular rehabilitation.

[Cooperative survey of the results of coronary surgery during cardiac rehabilitation]. / Enquête coopérative sur les suites de la chirurgie coronaire au cours de la réadaptation cardiaque.

The aim of this study was to assess the type and frequency of cardiac and extracardiac complications of coronary artery surgery in patients referred for cardiac rehabilitation (for which it is one of the principal indications): this was a prospective study carried out simultaneously in 30 cardiac rehabilitation units during December 1992 and including 533 patients (81 women, 452 men) with a mean age of 62.1 years. The total number of coronary grafts was 1,361 (on average 2.5 per patient); the internal mammary artery was used in 87% of cases; revascularisation was complete in 66.4% of patients. One or more complications were observed in 79% of patients during the hospital period (68.9%) and/or during the rehabilitation phase (44.7%), independently of age, sex, duration of cardiopulmonary bypass, or the interval to cardiac rehabilitation. The main extracardiac complications were respiratory (31.5%), disturbances of cerebral function (15.6%) and renal failure (10.3%). Cardiac complications comprised arrhythmias, essentially supraventricular (21.3%), infarction and residual postoperative ischaemia (8.4%), large pericardial effusion (7.5%), cardiac failure (4.5%), and wound infection (4.3% including 2.8% mediastinitis). Anaemia, a secondary effect of cardiopulmonary bypass, was observed in 25% of patients. This prospective study, though affected by a bias of selection and not fully representative of the surgical outcome, shows the need for a personalised management of these patients, the early indication of cardiovascular rehabilitation contributing to the optimisation of coronary artery surgery at less cost and with improved safety.

[Return to work of professional drivers after cardiac rehabilitation]. / Reprise du travail après réadaptation cardiaque chez les chauffeurs professionnels.

This study analysed the possibilities of returning to work of professional drivers after a cardiac event and rehabilitation. The population comprised 94 consecutive patients, all men, average age 48.8 years (range 30 to 63 years) referred after coronary bypass surgery (N = 39), myocardial infarction (N = 38), angina (N = 4) or valve replacement surgery (N = 13). Advice on professional reinsertion was given after the rehabilitation program, authorization to drive being given in the absence of cardiac symptoms, residual myocardial ischaemia, severe left ventricular dysfunction and serious ventricular arrhythmias. After 35 months, 4 patients were lost to follow-up; of the 90 remaining patients, the frequency of return to work (maximal at the 9th month) was 65.6% with 84.7% obtaining a renewal of their driving licence. In this series, 81% of patients were asymptomatic, 2 died, 16.7% had further cardiovascular complications. The morbidity and mortality were significantly greater in the group who had to stop driving (N = 40) (32.5% vs 8%, p < 0.001). Non complications occurred during work in those who resumed driving. This study confirms the safety of allowing low risk professional drivers, identified during cardiac rehabilitation by simple, reliable clinical and paraclinical criteria, to return to work.

Skin acceptance of transcutaneous nitroglycerin patches: a prospective study of 33 patients.

Transdermal nitroglycerin is commonly used and may induce contact dermatitis. The frequency of adverse skin reactions is controversial and may vary from 10% to 75%, according to various authors. 33 patients using transdermal nitroglycerin for more than 7 days were examined and patch tested (nitroglycerin 0.5% aq., 2% pet. and TTS in toto). 5 patients (15%) had adverse reactions. The patch tests were all negative in the 33 patients. Contact dermatitis occurs in many cases, about 15% of the cases with the newly available TTS, and even if patients respect the conditions for using TTS. These contact dermatitides are mainly irritant reactions and do not require transdermal nitroglycerin treatment to be stopped. Nevertheless, since some cases of allergic contact dermatitis have been reported, a contact dermatitis from transdermal nitroglycerin should lead to patch testing.

[Evaluation of the readaptation of patients with triple coronary vessel disease unfit for by-pass surgery]. / Evaluation de la réadaptation chez le coronarien tritronculaire non pontable.

The objective of this study is to evaluate the effects of rehabilitation in 46 consecutive patients with triple vessel coronary disease, and unfit for by-pass surgery: there were 45 men and 1 woman (mean age = 58 years), admitted during the 3rd week of a myocardial infarction (N = 31) or following unstable angina (N = 15). The stroke volume (SV) is normal in 50 p. cent of the patients, but 15 p. cent presented as SV less than 0.30. 3 patients were unable to start their rehabilitation because of unstable angina (N = 2), or severe pulmonary edema (N = 1). Following 4 weeks of rehabilitation, comparison of the stress tests pre- and post-rehabilitation, reveals improved functional capacities (maximum level reached 103.6 +/- 27 vs 126.4 +/- 31; p less than 0.001, and an improvement of the ischemic threshold (82 +/- 32 vs 92 +/- 31; p less than 0.05). During the long-term follow-up (32.5 months), 4 patients died from cardiac complications (8.7%) and one from extra-cardiac reasons. Among the 41 alive patients, 58.6 p. cent were asymptomatic, 39 p. cent presented cardiac complications, one had a GI malignancy. The rate of return to work among the active population is 68.5 p. cent within a mean time of 1.7 months after rehabilitation. Overall, this study demonstrates the possibility of cardiac rehabilitation under medical supervision in patients with severe triple vessel coronary disease. The improvement of the functional abilities under stress conditions is obvious, enabling the patient to regain confidence in him/herself and improve his/her comfort.

[Myocardial infarction related to the practice of sports. clinical and coronary angiography apropos of 35 cases]. / Infarctus du myocarde liés á la pratique sportive. Etude clinique et coronarographique á propos de 35 cas.

The clinical and coronary angiographic features of 35 patients who survived the acute phase of a myocardial infarction that occurred while they were practising sports were studied. 97 p. 100 of the patients were male. Mean age was 42.8 years (range 26-71 years), 60 p. 100 being over 40. All but 2 patients had risk factors, the most important of which were tobacco smoking (constant among young subjects) and high blood cholesterol level. In 1/3 of the cases the infarction was preceded by symptoms. 69 p. 100 of the patients were correctly trained. IN 46 p. 100 of the patients the signs of infarction appeared at the end of the physical exertion. Thirteen sports were concerned, notably football (9), tennis (7), cycling (5) and running (5). Contributing factors associated with the way physical exercise was performed with the environment or with the subject's general condition were often present. During a mean follow-up period of 25.3 months, 2 patients were lost sight of and 2 died, one of them of cardiac disease; 71 p. 100 remained asymptomatic. All patients underwent coronary angiography which showed coronary thrombosis in 60 p. 100 of the cases (100 p. 100 when angiography was performed at a very early stage and 33 p. 100 when it was performed more than 15 days after the infarction). One single vessel was involved in 40 p. 100 of the cases and several vessels in 34 p. 100. Angiography yielded normal results in 26 p. 100 of the patients, all of them aged less than 45 years.(ABSTRACT TRUNCATED AT 250 WORDS)

Return to work after rehabilitation in coronary bypass patients. Role of the occupational medicine specialist during rehabilitation.

The aim of the study was to assess the role of the occupational medicine specialist in improving return to work (RTW) after coronary bypass graft (CABG) surgery, with an early intervention in the rehabilitation programme of the patients. There were 57 patients (56 male, 1 female, mean age was 50.7 years), sent for rehabilitation 22 days after surgery (49% of them had a prior myocardial infarction, and the ejection fraction (EF) was greater than or equal to 0.55 in 67%, 0.30 less than EF less than 0.55 in 25%, or less than or equal to 0.30 in 8%; myocardial revascularization was complete in 47% of the patients). Jobs required a high level of physical activity in 52.5% of the patients, a medium or low level in 44% and 3.5% of the patients were unemployed. At 7 months follow-up, 73.2% out of the 56 alive patients had returned to work with a mean delay of 109.9 +/- 84 days after surgery. The causes of non-return to work were social and economical factors (46.6%), psychological factors (40%) and medical reasons (13.4%). No clinical data were correlated with return to work (age, EF, extent of revascularization, or results of the stress tests), but return to work varied with the energy requirement in jobs with 97.3% return to work in case of low physical level, and 46.7% in case of high physical level (P less than 0.001). The comparison with a previous study performed in 1984 in 45 rehabilitation patients (with non-systematic vocational counselling), showed an increase in return to work in cardiac patients from 51% to 78% (P less than 0.05) after intervention of the occupational physician. So, the different ways of improving return to work in post-CABG patients are complementary: exercise training and secondary prevention are important, but must be completed with individual vocational counselling that should be included in every rehabilitation programme.

Effects of a comprehensive rehabilitation programme in patients with three-vessel coronary disease.

The aim of the study was to assess the effects of rehabilitation in 46 consecutive three-vessel coronary disease patients who were considered to have no possibility of revascularization; there were 45 males and one female (mean age 58) sent in the third week after acute myocardial infarction (N = 31) or after unstable angina (N = 15). Left ventricular ejection fraction (EF) was normal in 50% of the patients, but 15% had an EF less than or equal to 0.30. Three patients could not begin their rehabilitation because of unstable angina (N = 2) or severe pulmonary oedema (N = 1). After a 4-week rehabilitation programme, the comparison of stress tests revealed an increase in functional capacities (maximal work-load = 103.6 +/- 27 W before rehabilitation, 126.4 +/- 31 W after rehabilitation, P less than 0.001), and an improvement of the ischaemic threshold [82 +/- 32 W before rehabilitation, 91 +/- 31 W after rehabilitation, P less than 0.05]. During long-term follow up [20.8 months], four patients died of cardiac events [8.7%]; all of them had an EF less than 0.45. Among the 42 living patients 61.9% were asymptomatic, 28.7% had exertional angina, and 9.4% had cardiac complications, and coronary surgery was performed in two cases with good results. The level of return to work was 85% with the mean delay of 1.7 months after rehabilitation. So, rehabilitation in three-vessel coronary disease patients is safe under medical control; improvements in exertional capacities are obvious and give the patients a better self confidence as assessed by the good score of return to work after rehabilitation.

[False positive of the exercise test and right auricular hypertrophy]. / Faux positif de l'épreuve d'effort et hypertrophie auriculaire droite.

Seldom mentioned as a possible etiology of false positive stress tests (ST), the right atrial hypertrophy (RAH) may cause electrocardiographic aspects evocative of myocardial ischemia in the lower areas. The retrospective study concerns STs in 4 patients, staying in a cardiac rehabilitation center, following (D14) surgery for isolated type II IAC, Fallot's trilogy (n = 1), or dual valvular disease (tricuspid insufficiency and mitral stenosis, n = 1), and presenting all on basal ECG a RAH (group I). These STs are compared to that of a reference group operated (D14) from a IAC type II (isolated n = 3, associated to RVPA n = 1), but without signs of RAH on the rest ECG (group II). All other possible causes of electrically positive STs were eliminated from this study. In patients with RAH, the stress test is positive in the lower area (ST = -1.27 +/- 0.25 mm). In four other patients without HAD, the STest is negative in 3 cases and uncertain in one. These results do not seem to be linked to pre-operative hemodynamic data, nor to sonocardiographic data. Atrial repolarization alone seems to be the cause of these ECG alterations during stress, as demonstrated, in one patient, by sudden variations of the ST segment during a change from an atrial rhythm (AR) (with retrograde atrial depolarization) to a sinus rhythm (SR). These observations suggest the role of atrial repolarization in the origin of false positive stress tests in patients with RAH.

[Therapeutic value of a combination of trimetazidine with a calcium inhibitor in the treatment of chronic coronary insufficiency]. / Intérêt thérapeutique de l'association de la trimétazidine avec un inhibiteur calcique dans le traitement de l'insuffisance coronarienne chronique.

This double-blind, placebo-controlled study sought to examine the short-term benefit of adding 60 mg of trimetazidine to the daily therapeutic regimen of 29 male patients with coronary insufficiency who had persistent ST depression on exercise tolerance test (greater than or equal to 1 mm), despite treatment with nifedipine 40 mg per day. As compared with the placebo group, after only 14 days, the patients treated with trimetazidine showed statistically significant increases in the maximum workload level attained before ST depression occurred (31% versus - 6%; P = 0.009), the total work performed (31% versus 2%; P = 0.024) and a significant decrease in the systolic tension time (double product)/workload ratio (-5% versus +11%; P = 0.005). Throughout the study the clinical acceptability was excellent, with no side effects attributable to trimetazidine being recorded. This study shows that the addition of trimetazidine to a calcium antagonist brings a valuable improvement in therapeutic results.