Effects of bisoprolol in patients with stable congestive heart failure.

AIM OF THE STUDY: To analyze the effect of bisoprolol in patients with stable congestive heart failure and who tolerated beta-blockers. MATERIAL AND METHODS: Two hundred and one patients performed before and 3 months after maximal tolerated doses of bisoprolol have been reached, a clinical evaluation, an echocardiography, a radionuclide angiography, a cardiopulmonary exercise test and hormonal determinations. RESULTS: Mean dose of bisoprolol was 8.8 +/- 2.4 mg/d. Patients had a significant improvement in NYHA classification. Heart rate at rest decreased from 87 +/- 17 to 66 +/- 12 beats/min (P < 0.0001) without any effect on electrocardiographic parameters. Left ventricular ejection fraction improved from 31 +/- 11 to 41 +/- 13% (P < 0.0001), with a significant decrease in end-diastolic and end-systolic left ventricle diameters and volumes. Mitral profile improved. Peak VO2 increased from 16.1 +/- 5 to 16.8 +/- 5.5 ml/min/kg (P = 0.001) with a significant increase in O2 pulse (from 8.52 +/- 2.7 to 11.2 +/- 3.5 ml/min/beats, P < 0.0001). Plasma levels of A-type and of B-type natriuretic peptides and of norepinephrine significantly decreased after bisoprolol. CONCLUSIONS: Bisoprolol significantly improved left ventricle ejection fraction with a reverse remodeling of the left ventricle, a decrease in hormonal activation and a modest improvement in exercise capacity.

[What tests should be conducted for secondary arterial hypertension in hypertensive patients resistant to treatment?]. / A quoi conduit la recherche d'une HTA secondaire chez des patients hypertendus résistant aux traitements?

UNLABELLED: The aim of this study was to determine the prevalence of secondary hypertension in a population of refractory hypertension without initial clinical or biological findings suggesting identifiable causes of hypertension. METHODS: A survey included 200 consecutive hypertensive patients referred to hypertension specialists for refractory hypertension (BP > 140/90 mmHg on at least two antihypertensive drugs). Prior inclusion, the permanent elevation of blood pressure was confirmed by ambulatory monitoring. In each subject an extensive work-up was performed to detect a secondary cause for hypertension. RESULTS: An essential hypertension was confirmed in 61% of this cohort. A secondary hypertension was detected in 20% of the patients; 8.5% with a primary hyperaldosteronism, 8% with a reno-vascular hypertension and 3% with a nephropathy. Moreover, 18.5% had a low renin hypertension. Thus, 27% of these patients had an abnormality of the renin-aldosterone axis. CONCLUSION: Patients with refractory hypertension should be explored to detect secondary hypertension even without findings suggesting such causes. This additional diagnostic procedure must include at least renovascular investigations and plasma renin/aldosterone level determinations in appropriate conditions.

[Inappropriate ADH secretion syndrome and hypereosinophilia in Horton disease with stenosis of the subclavian arteries]. / Syndrome de sécrétion inappropriée d'ADH et hyperéosinophilie au cours d'une maladie de Horton avec sténoses des artères sous-clavières.

The authors describe a case of giant cell arteritis with subclavian involvement in association with a syndrome of inappropriate anti-diuretic hormone secretion and hypereosinophilia. Subclavian involvement, which may be the first symptom, occurs in five to twenty percent of giant cell arteritis. Hypereosinophilia, a frequent manifestation of specific granulomatosis vasculitis, is rarely described in association with giant cell arteritis. Dysfunction of the hypothalamo-pituitary axis such as inappropriate anti-diuretic hormone secretion or diabetes insipidus has been recently reported in giant cell arteritis. The syndrome of inappropriate anti-diuretic hormone secretion may either reveal the disease or occur during the evolution, in particular with gradual reduction of steroid treatment. It may be isolated, without clinical feature of arteritis and without an elevated erythrocyte sedimentation rate. This inappropriate anti-diuretic hormone secretion, probably due to ischemic involvement of the pituitary or hypothalamic region, always improves quickly after institution of steroid therapy.

[Painful left bundle-branch block during exertion]. / Le bloc de branche gauche douloureux d'effort.

Two new cases of exercise related left-bundle branch block are reported in this study. They should be added to the twenty established and published cases. Comparison opens the way to discussion of the mechanism of onset. Ischemia is often accused, although no exploration has been able to demonstrate its responsibility in the origin of the problem. These two cases have novel features, particularly in describing the first case of painful exercise related bundle branch block in a subject twenty-three years of age. Ischemia linked to epicardial coronary lesions cannot be held responsible, but the possibility of micro-circulatory ischemia is suggested.

[Paroxysmal supraventricular tachycardia induced by deglutition]. / Tachycardie supra-ventriculaire paroxystique induite par la déglutition.

The authors report the case of a 43-year-old man with runs of tachycardia, sometimes atrial and sometimes by reentry, induced by atrial extrasystoles provoked by ewallowing. This rare condition, 21 descriptions of which are referred to, raises the problem of the inducing mechanism, with discussion of the role of mechanical stimulus played by the alimentary bolus or of a reflex of ortho- or parasympathetic origin. The discussion includes a detailed review of this condition and its treatment. The prognosis is always excellent but symptomatic discomfort may be considerable. Spontaneous recovery is possible, as in the case described here.

[Arterial thromboses and essential thrombocythemia in young patients]. / Thromboses artérielles et thrombocytémie essentielle chez le sujet jeune.

The authors report two cases of essential thrombocythemia (ET) which occurred in young subjects (25 and 33 years) and revealed by arterial thromboses. The first case was one of myocardial infarction: in the second case, ischemic signs in the left leg led to cutaneous necrosis. Thrombotic signs are commonplace in ET and are generally considered to be attributable to an impaired underlying vascular territory. The cases reported by the authors conflict with these data and it would seem, therefore, that the onset of thrombosis in the absence of any associated cardiovascular risk can be envisaged. With regard to therapy, if thrombotic signs occur, myelosuppressive treatment must be undertaken; in asymptomatic patients, due to the potential and unpredictable risk of thrombosis, this treatment should be initiated if the platelet count rises above 800 x 10(9)/l. Hydroxyurea is generally prescribed (particularly in young patients) since it is generally considered to be devoid of any leukemogenic potential.

[Refsum's disease. Apropos of 2 cases disclosed by myocardiopathy]. / La maladie de Refsum. A propos de deux cas révélés par une myocardiopathie.

Refsum's disease is a polyneuropathy due to a hereditary error in the metabolism of a fatty acid, phytanic acid, usually leading to cardiac failure only at an advanced stage of the disease. The authors report the case of two brothers with Refsum's disease revealed by a heart failure before the clinical stage of the peripheral neuropathy. In the younger brother, the affection started at the age of 22 years by an acute pulmonary oedema which revealed a dilated, hypokinetic myocardiopathy, associated with retinitis pigmentosa, ptosis, anosmia and biological myolysis. The normal plasma concentration of phytanic acid measured several times led to the conclusion of Kearns-Sayre syndrome even if certain aspects were atypical (moderate conduction disorders, no characteristic aspect in the muscle biopsy). Five years later, the older brother, aged 28, presents a dyspnea on effort which leads to the discovery of a hypokinetic, hypertrophic myocardiopathy, slightly dilated, associated with cardiac conduction disorders, retinitis pigmentosa, anosmia and biological myolysis. The plasma concentration of phytanic acid being very high. Refsum's disease was diagnosed and the diagnosis of younger brother was corrected. From the study of these two cases, the characteristics of the cardiac disorders can be specified: the cardiopathy can reveal the disease and correspond to a dilated or hypertrophic myocardiopathy. The diagnosis of the disease can be difficult because the plasma phytanic acid may remain at normal level, thus requiring the assay of the activity of phytanate oxydase. The existence of ophthalmologic signs (retinitis pigmentosa or progressive ophthalmoplegia externa) associated with a myocardiopathy must systematically lead to a search for Refsum's disease, this diagnosis having fundamental therapeutic implications (died, even plasmapheresis).(ABSTRACT TRUNCATED AT 250 WORDS)

[Unilateral left agenesis of the pericardium. Contribution of cardiac imaging]. / L'agénésie unilatérale gauche du péricarde. Apport de l'imagerie cardiaque.

The authors report a case of congenital absence of the left pericardium in a pauci-symptomatic young woman. Indirect signs in favour of this diagnosis were elicited on chest X-ray (levoposition of the heart, convex left heart border). An associated congenital heart lesion was excluded by Doppler echocardiography. Computed tomography and MRI showed the right pericardium to be present but the left pericardium (not always visible in normal subjects) and the pre-aortic recess (present in all normal subjects) were absent. Abnormal presence of lung tissue between the aorta and pulmonary artery, and also between the pulmonary artery and left auricle was, however, confirmed. Nevertheless, these investigations did not enable the authors to define the exact extent of the pericardial defect. Finally, the indirect signs of levocardioposition were the main diagnostic markers of congenital absence of the left pericardium which did not require surgery in this particular case.

[Heart valve involvement in lupus erythematosus disseminatus. Apropos of 2 cases. Review of the literature]. / Les atteintes valvulaires du lupus érythémateux disséminé. A propos de deux observations. Revue de la littérature.

Regarding two cases of idiopathic lupus valvulopathy, the authors review the various mechanisms responsible for the endocardial lesions in disseminated lupus erythematosus. In addition to the classic Libman-Sachs endocarditis, there are sclerous forms, ruptures of the chords, thromboses and bacterial superinfections. The role of steroid therapy in the genesis of valvular stenosis is not always determined. A surgical treatment, effective and without major risk, must be advocated at an early stage in the presence of poorly tolerated forms.

[Kidney angioplasty. Long-term clinical and angiographic results apropos of 50 patients]. / L'angioplastie rénale. Résultats cliniques et angiographiques à long terme à propos de 50 patients.

In order to evaluate the long-term results of renal angioplasty with a follow-up of at least 3 years, we reviewed the first 50 patients who were treated by this technique for renovascular hypertension. The 42 patients (85 p. 100) in whom the angioplasty was technically successful were followed up both clinically and radiologically, using intravenous digital angiography. The clinical follow-up lasted 52 months on average (range: 8 to 96 months) and reached 3 years or more in 37 patients (4 patients died and 1 was lost sight of). The hypertension returned in 19 of the 42 patients (45 p. 100), the relapse occurring after 24 months in 8 cases. Thirteen of these patients accepted a control angiography which showed restenosis in 11 cases. At the end of the follow-up period, and after a second dilatation in some cases, 30 (60 p. 100) of the 50 patients were found to have benefited from the angioplasty (20 p. 100 were cured and 40 p. 100 were improved). 80 p. 100 of the patients whose renal artery stenosis was due to fibromuscular dysplasia (n = 10) were cured or improved, as were 66 p. 100 of the patients with "localized atheroma" (n = 12), but patients with severe and diffuse atheromatous lesions (n = 28) did not respond so well (7 p. 100 cured, 43 p. 100 improved), and all the major complications of the procedure occurred in this group. The radiological follow-up was performed in 36 patients over a mean period of 31 months (range: 1 to 96 months).(ABSTRACT TRUNCATED AT 250 WORDS)

[Compression of the right pulmonary artery by chronic aortic dissection]. / Compression de l'artère pulmonaire droite par une dissection aortique chronique.

The authors report the case of a 56-year old woman who had presented with clinical symptoms resembling those of pulmonary embolism and due to chronic dissection of the first aortic segment compressing the right branch of the pulmonary artery. Eighteen months after the acute episode, the diagnosis was suspected at echocardiography, but the other paraclinical examinations performed (scintigraphy of the lung, angiography, computerized tomography) failed to display the aortic dissection, although they enabled the diagnosis to be approached and the physiopathology to be determined. At surgery, a type II dissection was discovered, the compression was relieved and the pulmonary artery was recanalized. The post-operative period was uneventful, with return to normal of the scintigraphic and CT images. This case is exceptional in that it is extremely rare (this is the 6 th case reported) and the lesion was well tolerated, probably due to the presence of a systemic-pulmonary circulation.

[Cardiac manifestations of Lyme disease. Apropos of a case]. / Manifestations cardiaques de la maladie de Lyme. A propos d'un cas.

A new case of heart involvement in Lyme's disease is reported. Its originality lies in its strictly isolated nature, therefore revealing the disease; in its typical picture of myocardopericarditis combining, in various stages, infra-hissian conduction disorders, bouts of left ventricular insufficiency, pseudoischemic repolarisation disorders and finally a moderate pericardial shift; in the demonstration, during two successive heart explorations by NMR (Nuclear Magnetic Resonance), of a diffuse myocardial hypertrophy, subsiding in time, as the other symptoms of this patient.

[Double compression of the celiac and mesenteric arteries by the arcuate ligament. An unusual cause of abdominal angina in young subjects]. / Compression coelio-mésentérique double par le ligament arqué. Une cause rare d'angor abdominal du sujet jeune.

The authors report the case of a 26 year-old woman hospitalized because of epigastric pain with onset a few years previously, occurring primarily after a heavy meal, and the recent discovery of a para-umbilical abdominal murmur with irradiation to the right iliac artery. The digital aortic angiography showed the absence of opacification of the coeliac trunk (CT) at its origin due to a very tight stenosis and a 50% narrowing of the proximal part of the superior mesenteric artery (SM). The abdominal ultrasonogram with pulsed Doppler clearly showed the very tight stenosis of the ostium of the CT and the stenosis of the S.M. Surgery confirmed the extrinsic compression of the two vessels by an aberrant fibromuscular bundle resembling an arcuate ligament. Section of this bundle completely freed the vessels. The course was favorable: the pain and murmur disappeared and there was no imprint on either vessel on the control angiography. In the discussion, the authors review the numerous atypical anatomical abnormalities which have been incriminated in the genesis of these compressions and analyze the resulting clinical syndrome. The contribution of the pulsed Doppler coupled with ultrasonography is discussed. Treatment is always surgical. This case provides an opportunity to review this exceptional entity represented by the double coeliac-mesenteric compression by the arcuate ligament. This is the first time a patient was examined by pulsed Doppler, which allows for rapid noninvasive and detailed work-up of the affection, entirely in agreement with the data obtained from the other examinations and the operative observations.

[Chronic aortic dissection disclosed by pericardial effusion. Apropos of 3 cases]. / Dissection aortique chronique révélée par un épanchement péricardique. A propos de trois cas.

Three exceptional cases of chronic aortic dissection revealed by a pericardial effusion are reported. The patients were two men and a woman admitted for thoracic pain or fever. Initial diagnoses were myocardial infarction, infective endocarditis and tuberculous pericarditis. The effusions were drained on two occasions. Because the pericardial fluid was a mixture of serum and blood, computerized tomography of the thorax and abdomen was performed. All three cases were then diagnosed as aortic dissection (type II in two cases and type III in one case, with retrograde extension to the ascending aorta). The authors underline the utility of drainage and the need for systematic CT scans in patients with sero-haematic pericardial effusion of uncertain origin.

[Value of pericardioscopy in pericardial effusion. Apropos of 20 patients]. / Intérêts de la péricardoscopie dans les épanchements péricardiques. A propos de 20 patients.

The value of pericardioscopy in pericardial effusion of uncertain origin was evaluated in 20 patients, aged from 18 to 77 years, whose pericardial effusion had been diagnosed by ultrasonography; 2 patients presented with clinical signs of tamponade. The cause of the pericarditis was unknown, but the clinical context suggested a malignant disease in 13 patients, tuberculosis in 5 patients and another cause in 2 patients. The pericardium was explored by means of a direct vision, cold-light endoscope, usually a mediastinoscope, introduced by the retroxiphoidal route under general of local anaesthesia. This method made it possible to study the pericardial fluid, examine the pericardial serous membrane, perform biopsies at a distance from the orifice of entry and cleanse the pericardium thoroughly in cases with blood or pus collection. Apart from 2 cases where the examination could not be completed because of an anterior mediastinal mass and a pericardial symphysis, valuable information could be obtained in purulent pericarditis (n = 1), chronic radiation induced lesions (n = 2), metastases (n = 2), haemopericardium (n = 2), and biopsies could be performed in tumoral or suspicious areas. These guided biopsies revealed a metastasis in 3 cases where the pericardial window was negative. No sign of tuberculosis was found in the 5 cases where the disease was suspected. The final diagnoses were: neoplastic pericarditis in 4 cases, radiation-induced pericarditis in 2 cases, purulent pericarditis in 2 cases, haemopericardium in 3 cases and idiopathic or reactive pericarditis in 9 cases. The post-operative period was uneventful, with no major complication ascribable to the procedure.(ABSTRACT TRUNCATED AT 250 WORDS)

[Treatment of acute non-chlamydial salpingitis. Study of the efficacy and tolerance of a single-therapy antibiotic: Augmentin]. / Traitement des salpingites aiguës non chlamydiennes. Etude de l'efficacité et de la tolérance d'un antibiotique en monothérapie: l'Augmentin.

An open randomised comparative trial of the efficacy and safety of Augmentin as against the triple therapy of penicillin-gentamicin-metronidazole in acute salpingitis was conducted in forty women admitted to hospital. Laparoscopy was performed routinely to confirm the diagnosis. The two groups of patients were comparable as to age and clinical and biological symptoms and the severity of the salpingitis (grade I to IV, with the presence or absence of Fitz-Hugh-Curtis syndrome). Treatment was started immediately after the laparoscopy, first by parental route until the patient had been apyrexic for 48 hours. Oral follow-up was then commenced. Twenty women received Augmentin and twenty the triple antibiotic therapy. Specimens for bacteriological study were obtained before treatment (culture of the urine, culture from the IUD and from the cervix, and swabs were taken laparoscopically). This made it possible to identify aerobic and anaerobic organisms. (The gonococcus was found more often in the group treated with triple antibiotics). On discharge, cures had been obtained in 12 women and 6 more were responding out of the Augmentin group. Out of the triple therapy group 8 were cured and 10 were responding. There was one failure in each group (persisting fever). Long-term assessment was carried out in the out-patients three weeks after discharge. 11 out of the 13 reviewed in the Augmentin group and 8 out of the 14 in the triple therapy group were considered as definitely cured. The clinical safety of both treatments was good. These results demonstrate that Augmentin is as effective as the combined therapy in treating acute salpingitis and with the added advantage of its easy use and lower cost.

[A rare cause of heart failure: hypocalcemic cardiopathy]. / Une cause rare d'insuffisance cardiaque: la cardiopathie hypocalcémique.

In this paper, the authors present the case of hypocalcemic cardiopathy observed in a female patient who underwent thyroidectomy which was complicated post-operatively by the development of hypoparathyroidism. Two attacks of heart failure experienced by this patient were improved by the administration of calcium in combination with digitalis treatment. A study of cases published in the medical literature reveals that this condition is a rare cause of heart failure which develops only in the course of chronic hypocalcemia, with few neuromuscular clinical manifestations. The dual negative inotropic and hypovolemic effects caused by hypocalcemia explain the efficacy observed with the administration of calcium therapy, while the usual symptomatic treatment of this condition is inadequate.