Atrial fibrillation detection with long-term continuous Holter ECG recording in patients with high cardiovascular risk and clinical palpitations: the prospective after study.

AIM: New technologic tools for continuous ECG monitoring have been developed to detect and treat atrial fibrillation (AF) in specific populations with high cardiovascular risk. We evaluated the prevalence and the management of AF diagnosed in patients with high cardiovascular risk and non-documented clinical palpitation undergoing systematic 14-day continuous ECG-Holter monitoring. METHODS: Patients were prospectively enrolled from December 2019 to December 2021 in this multicentre study, sponsored by the French National College of Cardiology. Patients met the following criteria: CHA2DS2VASc score ≥ 2 in males and ≥ 3 in females and clinical palpitations without previously documented arrhythmia. Enrolled patients underwent a continuous 14-day Holter-ECG monitoring for arrhythmia detection. RESULTS: Among the 336 included patients, 39% were male, 75% were greater than 65 years of age and 46.5% had suffered a prior stroke. AF was detected in 14% of patients, among which 23.4% were detected in the first 24 h of monitoring. Finally, age ≥ 65 years (p = 0.037) was significantly associated with AF, as well as male gender (p = 0.023) and a lower rate of antiplatelet therapy (p = 0.018). Patients with diagnosed AF had a prescription of anticoagulation therapy in 90%. Antiarrhythmic drugs were administered in 90% of AF patients and 13% underwent AF ablation. CONCLUSIONS: The systematic AF screening of patients with palpitations and high cardiovascular risk resulted in a diagnostic yield of AF in 14% of the population with a 14-day continuous ECG-Holter monitor. This strategy resulted in the prescription of anticoagulation and antiarrhythmic therapy in 90% of the AF detected population.

Diagnosis and management of heart failure from hospital admission to discharge: A practical expert guidance.

Heart failure (HF) has high event rates, mortality, and is challenging to manage in clinical practice. Clinical management is complicated by complex therapeutic strategies in a population with a high prevalence of comorbidity and general frailty. In the last four years, an abundance of research has become available to support multidisciplinary management of heart failure from within the hospital through to discharge and primary care as well as supporting diagnosis and comorbidity management. Within the hospital setting, recent evidence supports sacubitril-valsartan combination in frail, deteriorating or de novo patients with LVEF≤40%. Furthermore, new strategies such as SGLT2 inhibitors and vericiguat provide further benefit for patients with decompensating HF. Studies with tafamidis report major clinical benefits specifically for patients with ATTR cardiac amyloidosis, a remaining underdiagnosed and undertreated disease. New evidence for medical interventions supports his bundle pacing to reduce QRS width and improve haemodynamics as well as ICD defibrillation for non-ischemic cardiomyopathy. The Mitraclip reduces hospitalisations and mortality in patients with symptomatic, secondary mitral regurgitation and ablation reduces mortality and hospitalisations in patients with paroxysmal and persistent atrial fibrillation. In end-stage HF, the 2018 French Heart Allocation policy should improve access to heart transplants for stable, ambulatory patients and, mechanical circulatory support should be considered to avoid deteriorating on the waiting list. In the community, new evidence supports that improving discharge education, treatment and patient support improves outcomes. The authors believe that this review fills the gap between the guidelines and clinical practice and provides practical recommendations to improve HF management.

Total knee replacement with retention of both cruciate ligaments: a 22-year follow-up study.

We report on the long-term results of 163 bicruciate-retaining Hermes 2C total knee replacements in 130 patients at a mean follow-up of 22.4 years (20.3 to 23.5). Even when the anterior cruciate ligament had a partially degenerative appearance it was preserved as long as the knee had a normal anterior drawer and Lachman's test pre-operatively. The description and surgical technique of this minimally constrained prosthesis were published in 1983 and the ten-year clinical results in 1999. A total of 12% of the knees (20 of 163) in this study were revised because of wear of the polyethylene tibial insert. Excellent stability was achieved and the incidence of aseptic component loosening was 4.3% (seven of 163). The survival rate using revision for any reason as the endpoint was 82% (95% confidence interval 76.2 to 88.0). Although this series included a relatively small number of replacements, it demonstrated that the anterior cruciate ligament, even when partially degenerated at the time of TKR, remained functional and provided adequate stability at a long-term follow-up.

Discontinuation of statin therapy due to muscular side effects: a survey in real life.

BACKGROUNDS AND AIMS: To assess the burden of statin related muscular symptom in real life. METHODS AND RESULTS: We conducted a wide survey on 10,409 French subjects. Among these, 2850 (27%) had hypercholesterolemia and 1074 were treated with statins. Muscular symptoms were reported by 104 (10%) statin treated patients and led to discontinuation in 30% of the symptomatic patients. The main prescribed statins were low doses rosuvastatin, atorvastatin and simvastatin. Pains were the most commonly described symptoms (87%) but many patients also reported stiffness (62%), cramps (67%), weakness or a loss of strength during exertion (55%). Pain was localized in 70% but mostly described as affecting several muscular groups. Approximately 38% of patients reported that their symptoms prevented even moderate exertion during everyday activities, while 42% of patients suffered major disruption to their everyday life. CONCLUSION: Muscular symptoms associated with average dosage statin therapy are more frequent than in clinical trials and have a greater impact on patients' life than usually thought.

REACH: international prospective observational registry in patients at risk of atherothrombotic events. Results for the French arm at baseline and one year.

INTRODUCTION: Atherothrombosis is a systemic, diffuse disease associated with a high risk of cardiovascular morbidity and mortality. It is the main cause of death in Western populations, a major public health concern and its prevalence will further increase in the future. OBJECTIVES: To evaluate the rate of major vascular events at 1 year in French patients with confirmed atherothrombotic disease, recruited in the REACH international registry. METHODS: The REACH Registry has recruited 55.000 patients in 44 countries, aged at least 45 years and suffering from established atherothrombotic disease (EAD). In France, 713 investigators selected 3.514 patients with EAD between December 2003 and June 2004. Each investigator had to include 5 to 10 patients presenting after a first documented event of cerebrovascular disease (CVD), coronary artery disease (CAD) or lower limb peripheral arterial occlusive disease (PAD). The patients were followed up for 1 year with collection of major vascular events. RESULTS: Among the 3514 French patients with EAD in the REACH registry, 2.373 (68%) had documented coronary disease, 778 (22%) had an ischemic stroke and 923 (26%) had documented PAD. One quarter of CAD patients, one third of CVD patients and one half of PAD patients had another atherothrombotic disease localization. Follow-up at 1 year was documented for 3.373 patients with EAD. The 1-year event rate in patients who had EAD was a function of the number of atherothrombotic localizations: the vascular death rate was 1.8% if there was a single localization and 4.1% if there were 2 or 3 localizations, and the composite death, infarct and stroke rates were 3.8% and 7.2% respectively and 11.7% and 22.3% respectively if hospitalizations were added to the latter endpoint. CONCLUSION: The number of major vascular events during the first year is high in EAD patients although these patients were followed up on an outpatient basis and are considered to be stable. In patients with prior EAD, there was a close link between the incidence of major vascular events and the number of symptomatic arterial beds (2 or 3 sites). The risk of a major vascular event was twice as high in patients with polyvascular involvement than in those who only had one affected artery.

[MICROALB study: screening for microalbuminuria in type 2 diabetic hypertensive patients by general practitioners in France]. / Enquête MICROALB: dépistage de la microalbuminurie chez l'hypertendu diabétique de type 2 par le médecin généraliste en France métropolitaine.

OBJECTIVE: To determine the prevalence of microalbuminuria (MAU) detected by a specific urinary strip in type 2 diabetic hypertensive patients in metropolitan France. METHOD: Screening for MAU with a semi-quantitative strip measuring the albumin/creatinine ratio was performed by general practitioners (GPs) in 6 type 2 diabetic hypertensive patients. This screening method was considered reliable if a preliminary search for proteinuria was performed with a usual strip and the quality of the MAU reading was good. RESULTS: 3347 GPs screened 19,714 patients (60% M, average age 64 +/- 10 years): 43.3% had MAU. MAU screening was considered reliable for 6679 patients (61.8% M, average age 65 +/- 10 years): 48.5% had MAU (alb/creat ratio between 30 and 300 mg/g), and 10.7% had manifest MAU (alb/creat ratio >300 mg/g). In all cases, the prevalence of MAU increased with the severity of hypertension. In the population with a reliable MAU screen, the analysis of risk factors according to the level of MAU yielded the following results: [table: see text]. In the MAU+ group, the need for multiple antidiabetic (including insulin) and antihypertensive drugs was more frequent. In contrast to current guidelines, only a minority of patients received an antiplatelet agent (approximately 33%). CONCLUSION: Despite recommendations, screening for proteinuria in type 2 diabetic hypertensive patients is seldom performed. However, the prevalence of MAU was high in this patient population. The prevalence of comorbidities and risk factors was significantly higher in the MAU+ group, with less frequent BP control despite a more aggressive antihypertensive treatment.

Diacerein reduces the excess synthesis of bone remodeling factors by human osteoblast cells from osteoarthritic subchondral bone.

OBJECTIVE: Although cartilage degradation characterizes osteoarthritis (OA), there is evidence that remodeling of subchondral bone in this disease is a contributing factor. Therapeutic strategies to modify the metabolism of subchondral bone osteoblasts may be indicated to treat OA. We studied the effects of diacerein and rhein on the metabolic and inflammatory variables of OA subchondral osteoblasts. METHODS: Human OA primary subchondral osteoblast cells were used. The effect of diacerein and rhein at therapeutic concentrations (5-20 microg/ml) was determined by osteoblast phenotypic factors, alkaline phosphatase, osteocalcin, and cAMP; on metabolic agents urokinase plasminogen activator (uPA), plasminogen activator inhibitor-1 (PAI-1), and insulin-like growth factor-1 (IGF-1); and on inflammatory mediators interleukin 6 (IL-6), prostaglandin E2 (PGE2), and cyclooxygenase-2 (COX-2). RESULTS: Diacerein and rhein did not affect either basal and 1,25(OH)2D3 induced alkaline phosphatase or parathyroid hormone (PTH) stimulated cAMP formation. Conversely, they dose dependently and statistically inhibited 1,25(OH)2D3 induced osteocalcin release, a situation explained by a reduction of mRNA levels for osteocalcin. Of the metabolic factors, they inhibited the production of uPA, with rhein showing slightly more potency; inhibitions of 69% and 57% were reached at the highest concentration (20 microg/ml) of rhein and diacerein, respectively. Both drugs also inhibited the PAI-1 level, albeit at a much lower level than for uPA. Interestingly, determination of the uPA/PAI1 ratio revealed that both drugs inhibited it about 55%, suggesting a decrease in uPA activity. In contrast, IGF-1 levels only increased slightly when cells were treated with rhein but not with diacerein. A transient dose dependent effect was found on IL-6 production; an inhibition was noted at low drug concentrations, which returned to basal levels at the highest concentration tested. PGE2 levels increased exponentially and were related to a concomitant increase in COX-2 levels in response to both drugs. CONCLUSION: Our data indicate that diacerein and rhein do not appear to affect OA subchondral bone cells' basal cellular metabolism, yet both agents reveal a direct effect at reducing the synthetic activities of osteoblasts, which could be responsible for abnormal subchondral bone remodeling occurring during the course of OA.

Total knee arthroplasty with retention of both cruciate ligaments. A nine to eleven-year follow-up study.

BACKGROUND: Although many early designs of total knee arthroplasty allowed the retention of both cruciate ligaments, in most current designs of knee replacement systems, either both cruciate ligaments are removed or the posterior cruciate ligament alone is retained. This report is a review of a series of total knee arthroplasties in which both cruciate ligaments were retained. METHODS: The results of 163 total knee arthroplasties (130 patients) in which both cruciate ligaments were retained were assessed prospectively. One hundred and seven knees (eighty-nine patients) were followed for an average of ten years. There were thirty-four men and ninety-six women, and the average age at the time of the index arthroplasty was sixty-seven years (range, forty-two to eighty-four years). The diagnosis was osteoarthritis in 122 (75 percent) of the knees and rheumatoid arthritis in forty-one (25 percent). Twenty-six knees had a valgus deformity, 109 had a varus deformity, and twenty-eight had a normal alignment of 5 to 10 degrees of valgus. The anterior cruciate ligament was relatively normal in ninety-six knees and was partly degenerated in sixty-seven knees. With use of the rating system of the Knee Society, all 163 knees were prospectively evaluated at yearly intervals; fifty-six of these knees (in forty-one patients) were followed in this manner until the patient died or was lost to follow-up. RESULTS: One hundred and four (97 percent) of the 107 knees available for study at an average of ten years had an excellent or good result. At the time of the latest follow-up, pain was adequately relieved in ninety-seven knees (91 percent) and the average range of flexion was 107+/-12.6 degrees (range, 65 to 135 degrees). Ninety-five knees (89 percent) had normal anteroposterior stability (less than five millimeters of movement in this plane), and twelve knees (11 percent) had five to ten millimeters of movement as demonstrated by the drawer sign. Ninety-six knees (90 percent) had normal mediolateral stability, and eleven (10 percent) had 5 to 10 degrees of laxity. Ninety-four knees (88 percent) had valgus alignment of 5 to 10 degrees. The average knee score was 91+/-8.4 points (range, 54 to 100 points), and the average functional score was 82+/-21 (range, 10 to 100 points). The survival rate at ten years, with revision as the end point, was 95+/-2.0 percent. Seven (4 percent) of the 163 knees in this series were revised. There were no revisions for patellar problems or aseptic loosening of the tibial component. CONCLUSIONS: The good anteroposterior stability in this series after an average follow-up period of ten years indicates that both the anterior and the posterior cruciate ligaments, even when partly degenerated, remain functional when they are preserved in a total knee arthroplasty.

[Outcome of traumatic tricuspid insufficiency, treated surgically. Apropos of 9 cases]. / Devenir de l'insuffisance tricuspide traumatique opérée. A propos de neuf cas.

Between 1983 and 1992, 9 patients with traumatic tricuspid regurgitation underwent surgical correction. The population consisted of young male adults (mean age 39 years). The trauma was usually due to a road traffic accident (n = 6). The mean interval to diagnosis was long (11 years). Echocardiography was diagnostic and showed the mechanisms. The usual lesion observed at surgery was subvalvular rupture of the anterior papillary muscle (n = 5). Surgery consisted of valve repair with annuloplasty and eight valve replacements for chronic retractile lesions. Six patients are still being followed up (average 7 years). There were no peroperative complications. Two patients underwent a second valve replacement for degeneration of a bioprothesis. Conduction defects requiring permanent cardiac pacing were not uncommon (n = 3) The delay before diagnosis may be explained by the diversity of lesion of the tricuspid valve, associated cardiac disease and the requesting of echocardiography. Surgical indications are mainly based on clinical signs. Even if long-term results are satisfactory, earlier diagnosis would probably allow more conservative surgery with preservation of right ventricular geometry and function.

[Pleuropericarditis complicated of tamponade disclosing mixed connective tissue disease. Remission with non-steroidal anti-inflammatory agents. Apropos of a case]. / Pleuropéricardite compliquée d'une tamponnade révélatrice d'une connectivite mixte. Régression sous anti-inflammatoires non stéroïdiens. A propos d'un cas.

Mixed connective tissue diseases or Sharp's syndrome are inflammatory diseases essentially presenting in the form of joint, muscle and skin manifestations. Pleuropericardial involvement is uncommon and rarely the presenting sign, and tamponade is exceptional. This clinical report concerns a case of pleuropericarditis complicated by tamponade in a 22-year-old man, constituting the presenting sign of Sharp's syndrome. The diagnosis of mixed connective tissue disease was based on the combination of clinical signs and a high serum anti-RNP antinuclear antibody titre. The treatment of the pericarditis is base on prescription of corticosteroids, but non-steroidal anti-inflammatory drugs were sufficient in our case. Larger effusions may require corticosteroids and pericardial drainage. We report the value of immunological assays in the aetiological assessment of pleuropericarditis in young subjects.

[Therapeutic problems in neurological bladder in the child (author's transl)]. / Problèmes thérapeutiques dans les vessies neurologiques de l'enfant.

On the basis of a retrospective review of 116 cases of neurological bladder in children, consisting essentially of patients with spina bifida and meningomyelocoele, the authors consider their present attitude to this problem. They take a simple neurological classification as a basis, and the various forms of treatment (cutaneous ureteric transplantation, physiotherapy, divulsion, sphincterotomy, anti-reflux plastic procedures, treatment of incontinence) are reviewed in terms of method, indications and results.