[The value of repeated determinations of brain natriuretic peptide for the diagnosis of unstable angina]. / Intérêt des dosages répétés du brain natriuretic peptide pour le diagnostic d'angor instable.

The diagnosis of unstable angina (troponine undetectable) is often difficult in the absence of electrocardiographic changes after suggestive chest pains. The object of this study was to analyse the kinetics of Brain Natiuretic Peptide (BNP) during acute coronary syndromes (ACS) without ST elevation. Plasma BNP was measured every 6 hours for 48 hours in 65 patients admitted for suspicion of ACS without ST elevation and without clinical, radiological or echocardiographic signs of left ventricular dysfunction. The results of BNP measurements were masked until the final diagnosis was established on the usual investigations (ECG changes, troponine I values, myocardial scintigraphy, coronary angiography). These investigations identified 3 groups of patients: non-Q wave infarction (group A: 19 patients), unstable angina (group B: 21 patients) and non-coronary chest pain (group C: 25 patients). The peak BNP was significantly higher in groups A (210 +/- 172 pg/ml) and B (152 +/- 159 pg/ml) than in group C (16 +/- 14 pg/ml). However, the BNP was normal or only slightly increased (< 50 pg/ml) in 25% of cases of ACS. Analysis of the kinetics of BNP was much more discriminating: early increase after the pain, peak between the 14th and 24th hours (19th hour on average), followed by a progressive decrease. The kinetics were identical in Groups A and B, contrasting with the flat profile of the curve in group C. A change of > 20 pg/ml in BNP was a better criterion of ACS with a diagnostic accuracy > 90% than increased troponine (group A) or undetectable troponine (group B). The authors conclude that BNP kinetics is a new and reliable diagnostic marker of unstable angina when the usual criteria of ACS are not present (notably a normal ECG and undetectable troponine).

[Efficacy and tolerance of propafenone after correction of atrial fibrillation: PEPS pharmaco-epidemiologic study]. / Efficacité et tolérance de la propafénone après régularisation de la fibrillation auriculaire: étude pharmaco-épidémiologique PEPS.

The PEPS study had the objective of documenting the acceptability and efficacy of propafenone in 1366 treated patients, after correction of chronic or paroxysmal AF, and followed up over one year. All the cases were validated by quality controls performed by the 196 participating cardiologists. All the events during follow up were validated by a committee of independent experts. The patients, aged 67 +/- 11 years, were in sinus rhythm on inclusion. Propafenone was prescribed at the initial dose of 600 mg/day in 65% of patients. The proportion of patients without relapse of AF was 64 +/- 1% at 12 months. After adjustment, the significant predictors of AF relapse were male sex, previous history of chronic AF and prescription of associated drugs. Neither patient age nor propafenone dose significantly influenced AF relapse. Seven deaths (0.5%) occurred during the study of which 3 were of unknown cause. A pro-arrhythmic effect was observed in 8 patients (0.59%) of which 6 had underlying heart disease. The overall frequency of pro-arrhythmic effects, including the 3 deaths of unknown cause, was therefore 0.81%. Tolerance of treatment with propafenone after correction of AF is therefore satisfactory and the frequency of pro-arrhythmic effects is less than 1%. The efficacy of the treatment for the maintenance of sinus rhythm is in accordance with previously published results.

Assessment of left ventricular regional wall motion by color kinesis technique: comparison with angiographic findings.

The analysis of segmental wall motion using two-dimensional (2-D) echocardiography is subjective with high interobserver variability. Color kinesis is a new technique providing a color-encoded map of endocardial motion. We evaluated the accuracy of color kinesis and 2-D for assessment of regional asynergy compared with left ventricular angiography as a reference method. Fifteen patients admitted for myocardial infarction were studied by echocardiography the day before left ventricular angiography. The left ventricle was divided into seven segments. Each segment was classified by two independent observers as normal or abnormal in 2-D and color kinesis. Accuracy of color kinesis and 2-D was evaluated and compared to left ventricular angiography. Color kinesis is significantly superior to 2-D for all seven segments (mean 0.80/0.68, P = 0.05), except for the septum (0.67/0.60, P = NS). Interobserver variability studied by chi-square statistic is lower with color kinesis (0.70) than with 2-D (0.57). We conclude that these data suggest that color kinesis is a useful method for assessing systolic wall motion in all segments, except the septum and for improving the accuracy of segmental ventricular function and interobserver variability.

[Left ventricular kinetics studied by the color kinesis method. Comparison of bidimensional echographic and angiographic data]. / Etude de la cinétique ventriculaire gauche par la technique du color kinesis. Comparaison aux données échographiques bidimensionnelles et angiographiques.

The object of this study was to assess the value of CK in the evaluation of left ventricular wall motion. Fifteen coronary patients aged 56 +/- 12 years were included: 8 patients were examined after acute myocardial infarction and 7 after unstable angina with a history of myocardial information. The left ventricle was divided into 7 segments after a modified Heger model, excluding the basal septal and basal lateral segments not seen on angiography. The left ventricular wall motion was assessed in two-dimensional echocardiography (2DE) and colour kinesis (CK) by two observers and compared with the results of left ventriculography, considered the reference method. Over all the 105 segments studied (7 segments for each of the 15 patients), CK was significantly better than 2DE (80% of segments correctly evaluated by CK vs 68% by 2DE, p < 0.05). Colour kinesis significantly improved the study of all segments except the interventricular septum (67% vs 60%, p = NS). The inter-observer variability in 2DE and CK evaluated over 135 segments (9 per patient) by the kappa was improved by colour kinesis (0.57 in 2DE, 0.7 in CK). The authors conclude that CK enables evaluation of left ventricular wall motion with greater precision and less inter-observer variability.

[Kearns-Sayre syndrome. A rare indication for prophylactic cardiac pacing]. / Syndrome de Kearns-Sayre. Une indication rare d'implantation prophylactique de pacemaker.

The authors report a case of Kearns-Sayre syndrome, a rare mitochondrial myopathy, diagnosed in a 19 year old man. Distal conduction defects are constant findings and are a dominant factor in the prognosis of this condition. Their early appearance and rapid progression pose the problem of prophylactic cardiac pacing despite the young age. In the case report, pacing was decided at the age of 23 in the absence of symptoms but with bifascicular block (right bundle branch block and left anterior hemiblock), without electrophysiological investigation. During follow-up, left bundle branch block was observed 3 years later and permanent complete atrioventricular block occurred 7 years after pacemaker implantation.

[Anomalies of the T waves induced by flecainide]. / Anomalies des ondes T induites par le flécaïnide.

Flecainide is a class I antiarrhythmic agent which depresses depolarization and conduction velocities in myocardial and Purkinje's fibres, thereby extending their refractory period. As the drug belongs to the IC group, it may increase--moderately as a rule--the duration of QRS, but it does not alter the action potential duration and therefore does not increase the JT interval. In 3 patients treated with flecainide we observed a peculiar alteration in the shape of T waves, the peak of which was flattened and notched, forming a double hump. This abnormality, most clearly visible on precordial leads, remained isolated with no changes in other electrocardiographic parameters. It appeared independently of any circumstance likely to modify repolarization. It remained stable throughout treatment with flecainide and vanished when the drug was discontinued. It was regularly observed with the recommended therapeutic doses (200-300 mg/day) and was unaccompanied by signs of toxicity. To our knowledge, these T wave abnormalities have not yet been reported. Yet they deserve to be known and correctly interpreted, since they reflect impregnation of the myocardium by the antiarrhythmic agent which should not be withdrawn on this account.