Comparative efficacy of a two-hour regimen of streptokinase versus alteplase in acute massive pulmonary embolism: immediate clinical and hemodynamic outcome and one-year follow-up.

OBJECTIVES: This study sought to compare the efficacy of 2-h regimens of alteplase and streptokinase in acute massive pulmonary embolism. The primary end point was immediate hemodynamic improvement, and secondary end points included early clinical efficacy and safety, as well as 1-year clinical outcome. BACKGROUND: Several thrombolytic regimens have been compared for the past 10 years in randomized studies, showing that 2-h infusion regimens of alteplase or urokinase lead to faster hemodynamic improvement than former 12- to 24-h administration protocols in acute massive pulmonary embolism. Many trials have focused on immediate hemodynamic and angiographic outcomes, but none has addressed long-term follow-up after thrombolysis. METHODS: Sixty-six patients with acute massive pulmonary embolism (Miller score > 17 and mean pulmonary artery pressure >20 mm Hg) were randomly assigned to receive either a 100-mg 2-h infusion of alteplase (n = 23) or 1.5 million IU of streptokinase over 2 h (n = 43). In both groups, heparin infusion was started at the end of thrombolytic infusion and adapted thereafter. Total pulmonary resistance was monitored over a 12-h period. Pulmonary vascular obstruction was assessed 36 to 48 h after thrombolytic therapy. One-year follow-up information included death, cause of death, recurrent pulmonary embolism, chronic thromboembolic pulmonary hypertension, stroke and bleeding. RESULTS: Both groups had similar baseline angiographic and hemodynamic characteristics of severity, with maintained cardiac output in 64 (97%) of 66 patients. The results (mean +/- SD) demonstrated that despite a faster total pulmonary resistance improvement observed at 1 h in the alteplase group compared with the streptokinase group (33+/-16% vs. 19 16%, p = 0.006), a similar hemodynamic efficacy was obtained at 2 h when both thrombolytic regimens were completed (38+/-18% vs. 31+/-19%). There was no significant difference in either pulmonary vascular obstruction at 36 to 48 h or bleeding complication rates. One-year event-free survival was similar in both groups, as most events were related to concomitant diseases. CONCLUSIONS: These results suggest that a 2-h regimen of streptokinase can be routinely used in patients with massive pulmonary embolism and maintained cardiac output without obviously compromising efficacy or safety.

Effect of pravastatin on angiographic restenosis after coronary balloon angioplasty. The PREDICT Trial Investigators. Prevention of Restenosis by Elisor after Transluminal Coronary Angioplasty.

OBJECTIVES: This study sought to determine whether pravastatin affects clinical or angiographic restenosis after coronary balloon angioplasty. BACKGROUND: Experimental data and preliminary clinical studies suggest that lipid-lowering drugs might have a beneficial effect on restenosis after coronary angioplasty. METHODS: In a multicenter, randomized, double-blind trial, 695 patients were randomized to receive pravastatin (40 mg/day) or placebo for 6 months after successful balloon angioplasty. All patients received aspirin (100 mg/day). The primary angiographic end point was minimal lumen diameter (MLD) at follow-up, assessed by quantitative coronary angiography. A sample size of 313 patients per group was required to demonstrate a difference of 0.13 mm in MLD between groups (allowing for a two-tailed alpha error of 0.05 and a beta error of 0.20). To allow for incomplete angiographic follow-up (estimated lost to follow-up rate of 10%), 690 randomized patients were required. Secondary end points were angiographic restenosis rate (restenosis assessed as a categoric variable, > 50% stenosis) and clinical events (death, myocardial infarction, target vessel revascularization). RESULTS: At baseline, clinical, demographic, angiographic and lipid variables did not differ significantly between groups. In patients treated with pravastatin, there was a significant reduction in total and low density lipoprotein cholesterol and triglyceride levels and a significant increase in high density lipoprotein cholesterol levels. At follow-up the MLD (mean +/- SD) was 1.47 +/- 0.62 mm in the placebo group and 1.54 +/- 0.66 mm in the pravastatin group (p = 0.21). Similarly, late loss and net gain did not differ significantly between groups. The restenosis rate (recurrence > 50% stenosis) was 43.8% in the placebo group and 39.2% in the pravastatin group (p = 0.26). Clinical restenosis did not differ significantly between groups. CONCLUSIONS: Although pravastatin has documented efficacy in reducing clinical events and angiographic disease progression in patients with coronary atherosclerosis, this study shows that it has no effect on angiographic outcome at the target site 6 months after coronary angioplasty.

Von Willebrand factor in diabetic angiopathy.

Diabetes mellitus is a complex disease characterised by chronic hyperglycaemia responsible for complications affecting the kidneys, eyes, peripheral nerves and micro- and macrovascular systems. Von Willebrand factor (vWf), a multimeric glycoprotein mainly synthesised by endothelial cells, is involved in platelet adhesion and aggregation and acts as the carrier of coagulation factor VIII in plasma. Increased levels of vWf, reflecting activation of or damage to endothelial cells, have been described in association with atherosclerosis and diabetes. vWf appears to be a predictive marker of diabetic nephropathy and neuropathy, although not of retinopathy, which suggests that endothelial dysfunction precedes the onset of diabetic microangiopathy. This dysfunction could be especially involved in the pathogenesis of renal abnormalities of diabetes. vWf is not a predictive marker of macroangiopathy when diabetes is associated with atherosclerotic risk factors. In the presence of chronic diabetic complications, vWf levels are not associated with any grade of retinopathy but increase with the severity of nephropathy and would appear to be a risk factor for macrovascular mortality in these patients. The endothelial dysfunction of diabetes can generate atherosclerotic lesions responsible for damage to the arterial wall, atheroma and formation of platelet microaggregates. Concomitant with high vWf levels, other possible mechanisms of endothelial damage include reduced synthesis or release of nitric oxide, hyperglycaemic pseudohypoxia and protein kinase-C activation, increased synthesis of proteins bearing advanced glycosylation end-products or transforming growth factor-beta (TGF-beta) activation of coagulation and inhibition of fibrinolysis. At present, it is not known whether high vWf levels are inherent to the physiopathology of diabetes, nor whether diabetes induces endothelial dysfunction through other pathways. However, since angiopathy resulting from endothelial dysfunction is the main cause of morbidity and mortality in diabetic patients, appropriate therapy is necessary to reduce these complications. Glycaemic control seems to be insufficient to normalise plasma vWf, whereas a decrease can be obtained by ingestion of diets rich in oleic acid or by treatment with statins. Inhibition of the binding of vWf to the GPlba receptor by synthetic peptides, aurin tricarboxylic acid or monoclonal antibodies has been proposed to prevent the thrombosis induced by high levels of plasma vWf. Thus, vWf probably represents an interesting target for the inhibition of thrombosis in diabetes.

Sensitivity and long-term prognostic value of cardiac troponin-I increase shortly after percutaneous transluminal coronary angioplasty.

BACKGROUND: After successful coronary interventions, minor elevations of creatine kinase MB (CK-MB) identified a population with a worse long-term prognosis than that in patients without enzyme elevations. In that setting, cardiac troponin-I (cTn-I), a highly specific marker for myocardial injury, was considered for a small study; the results did not support the view that significant myocardial damage occurred during successful percutaneous transluminal coronary angioplasty (PTCA). HYPOTHESIS: The present study was designed to assess the rate of elevated values of cTn-I after successful PTCA and to determine its prognostic value. METHODS: CTn-I and CK-MB were measured in 44 patients before and daily for 3 days after PTCA. Two groups of patients were considered according to the presence or absence of elevated levels of cTn-I. The rate of free-event survival was estimated for the two groups using the Kaplan-Meier method and was compared with the log rank test. RESULTS: Globally, 36% of patients had an increase in cTn-I (normal values 0.35 ng/ml) and 9% had an increase in CK-MB, p = 0.002. The mean time to maximal enzyme level was 1.8 days for cTn-I and 2.2 days for CK-MB. Over a follow-up of 1375 +/- 416 days, 18% of patients experienced adverse events, and cTn-I did not identify a population of worse long-term prognosis. CONCLUSION: These results suggest that cTn-I is more sensitive than CK-MB in identifying minor myocardial damage after PTCA, but these elevated concentrations of cTn-I in the short-term aftermath of angioplasty do not seem to be a marker of worse long-term prognosis.

[Concealed permanent ventricular reentry and paroxysmal ventricular tachycardia by circulatory movement]. / Réentrée ventriculaire permanente cachée et tachycardie ventriculaire paroxystique par mouvement circulaire

Endocavitary recording in a patient with attacks of ventricular tachycardia demonstrated a late potential which activated the bundle of His in a retrograde fashion, and the right bundle branch in a forwards direction. This late potential is evidence of a persistant ventricular microeentry which cannot be seen on the peripheral leads. In certain conditions which have been studied, this localised microreentry leads to ventricular tachycardia by macroreentry using the branches of the bundle of His. Tanks to this unusual case, we were able to study the effects of certain anti-arrhythmic drugs on the micro- and macroreentry circuits. By these means a therapeutic solution has been found for paroxysms of ventricular tachycardia.

[Drug therapy of acute myocardial infarction without cardiogenic shock and thrombolytic therapy excluded]. / Les traitements médicamenteux de l'infarctus aigu du myocarde en dehors du choc cardiogénique et à l'exclusion de la thrombolyse.

Myocardial infarction is responsible for 25,000 deaths per year in France and is a real problem of public health. The management of patients victims of this condition is an important feature of medical practice. Thrombolytic therapy has resulted in significant improvements in the reduction of the size of the infarct, in the conservation of left ventricular function and in the reduction of mortality. Treatment of the acute phase of myocardial infarction, especially when there are contra-indications to thrombolysis, comprises other approaches, some of which are old, which are reviewed in the light of the results of the latest large scale therapeutic trials.

[Cardiac involvement in a lupus syndrome. Clinical and morphological study apropos of one case necessiting a double valve replacement]. / Atteinte cardiaque au cours d'un syndrome lupique. Etude clinique et morphologique à propos d'un cas ayant nécessité un double remplacement valvulaire.

A patient with disseminated lupus erythematosus developed mitral and aortic valve disease, requiring double valve replacement. The ultra-structure of the lesions of the endo- and myocardium are described, and their significance discussed.

[Isolated right heart failure in acute lymphocytic myocarditis]. / Décompensation cardiaque droite isolée lors d'une myocardite aiguë lymphocytaire.

The authors report a case of acute myocarditis, presenting with signs of isolated right heart failure which was progressive and fatal. This is a very rare observation which poses diagnostic problems. A review of the literature showed only 4 previous reports, all diagnosed at autopsy, in which the diagnosis was not suspected in vivo. In our case, echocardiography raised the possibility of myocarditis at an early stage, although the initial clinical signs were atypical and did not indicate right ventricular disease. It is particularly important to detect right ventricular involvement, especially when associated with left ventricular disease, as the prognosis is very poor. This case report illustrates the difficulty of the differential diagnosis and shows the diagnostic and prognostic value of echocardiography when interpreted in the clinical and electrocardiographic context.

[Value of transesophageal auricular stimulation for evaluating the accessory pathway and effect of treatment in Wolf-Parkinson-White syndrome]. / Intérêt de la stimulation auriculaire transoesophagienne pour évaluer la voie accessoire et l'effet du traitement dans le syndrome de Wolff-Parkinson-White.

In order to assess the value of the various atrial pacing techniques employed to evaluate the anterograde conduction of the accessory pathway and the effect of antiarrhythmic agents in Wolff-Parkinson-White syndrome, transesophageal atrial pacing was performed in 12 patients before and during treatment with oral flecainide acetate in doses of 200 mg per day. Before treatment, the shortest interval conducted with a 1/1 atrioventricular conduction by the accessory pathway ranged from 225 to 600 ms (mean 311 +/- 98 ms), and the effective refractory period of the accessory pathway, measured by the extrastimulus method in 11 patients, varied from 240 to 320 ms (mean 273 +/- 22 ms). These two values were very close in each patient and correlated well with each other (r = 0.90; p less than 0.001). Atrial fibrillation could be induced in 3 patients. Three patients were considered "at risk" since their effective refractory period or minimal R-R interval in atrial fibrillation was 250 ms or less. Tachycardia was induced in 8 patients, and it was possible to induce arrhythmias in the 6 patients for whom we had recordings in spontaneous tachycardia. Under treatment with flecainide acetate, an anterograde conduction block appeared in 3 patients. In the remaining 9 patients the shortest interval conducted with a 1/1 atrioventricular conduction by the accessory pathway was longer in every case: it ranged from 270 to 540 ms (mean 407 +/- 84 ms; p less than 0.001), which corresponded to a 20 to 240 ms prolongation (mean 133 +/- 78 ms).(ABSTRACT TRUNCATED AT 250 WORDS)

[Nuclear magnetic resonance in the diagnosis of aortic diseases]. / Apport de la résonance magnétique nucléaire dans le diagnostic des affections aortiques.

The diagnostic value of nuclear magnetic resonance imaging was assessed in a number of aortic pathologies: aneurysms of the thoracic and abdominal aorta, sinus of Valsalva aneurysms and dissection of the aorta. The imager was equipped with a resistor magnet providing a field of 0.15 Tesla. An electrocardiographic gating system was perfected. The images obtained were very satisfactory as they provided three dimensional morphological information and a qualitative assessment of blood flow. Further studies are now required with comparison with other invasive and non-invasive diagnostic methods to determine the clinical role of NMR imaging and to evaluate the diagnostic sensitivity and specificity of this new technique.

[The spatial vectorcardiogram loop. Estimation of its planarity by the calculation of a distortion coefficient. Trial of clinical evaluation]. / Etude de la boucle du vectorcardiogramme spatial. Appréciation de sa planéité par le calcul d'un coefficient de gauchissement. Essai d'évaluation clinique.

Automatic techniques for interpreting the electrical activity of the heart are based more and more on vectorcardiographic parameters, especially information provided by the spatial vectorcardiographic loop. This data has been shown to be a useful complement to classical electrocardiography. The aim of this study was to define a method of calculation of the planes of the vectorcardiographic loops of depolarisation and repolarisation, and to calculate a coefficient of left-sidedness obtained by the sum of squares of the distances between the points on the loop in the plane. This value is then normalised with respect to the size of the loop. Normal values of this coefficient were first defined in a healthy reference population of 70 subjects: the values are expressed in (MV/10)2 or in mm2, and are 0,28 +/- 0,05 for the QRS and 0,0026 +/- 0,0008 for the ST-T. The coefficient was then calculated in different pathological groups, the diagnosis of which had been formally confirmed: ventricular hypertrophy, valvular heart disease, conduction defects, coronary artery disease. The highest values (four times normal) were obtained in right ventricular hypertrophy, right bundle branch block and infarction associated with conduction defects. The discriminative value of the coefficient of left-sidedness is discussed with the aim of distinguishing the normal from the pathological.

[Value of the analysis of pulmonary venous flow in the evaluation of hemodynamics in dialysed patients]. / De l'intérêt de l'analyse du flux veineux pulmonaire dans l'estimation d'un état hémodynamique. Exemple de la dialyse.

The aim of this study was to assess the value of analysis of pulmonary venous flow in the evaluation of the haemodynamic status of patients with chronic renal failure with normal left ventricular function, treated by haemodialysis. Pulmonary venous flow was recorded immediately before and after haemodialysis in 27 patients with chronic renal failure and a mean age of 44 years. Three groups of patients were defined according to the change in mitral E/A ratio: Group I (E/A < 1 before and after dialysis), Group II (E/A > 1 before and < 1 after dialysis) and Group III (E/A > 1 before and after dialysis). There was a significant difference between these subgroups before dialysis with respect to age, S, D, VTI S, Total VTI, VTI S/Total (p < 0.05). However, because the values overlapped, only a VTI S/Total ratio greater than 59% differentiated patients in Group II from those in group III (p < 0.05). After dialysis, the change in S/D and VTI S/Total ratios increased in Groups I and II and decreased in Group III. The authors concluded that 63% of patients without LV dysfunction on haemodialysis have abnormalities of relaxation which are latent in 47% of cases due to increased filling pressures diagnosed by a VTI S/Total ratio > 59% or simply because the patients are over 50 year old.

[Induction of ventricular tachycardia by esophageal stimulation. Apropos of 2 cases]. / Déclenchement d'une tachycardie ventriculaire par stimulation oesophagienne. A propos de 2 observations.

The utility of transesophageal atrial pacing in sustained left ventricular tachycardia is reported in two cases. A 46 year old man without any apparent cardiac disease presented with invalidating but undocumented palpitations. Transesophageal atrial pacing with isoproterenol infusion induced wide complex tachycardia with a right bundle branch block morphology and left axis deviation. Atrio-ventricular dissociation was observed and it was possible to reduce the ventricular complex width by rapid transesophageal atrial pacing: the tachycardia was terminated by an injection of verapamil. It was not possible to reinduce the tachycardia after treatment with atenolol 100 mg/day, introduced because of the catecholinergic nature of the arrhythmia. The patient is symptom free after 2 years of treatment with this drug. Regular wide complex tachycardia with right bundle branch block and left axis deviation without any detectable atrial activity was recorded in a 50 year old man without known cardiac disease. Transesophageal atrial pacing with isoproterenol infusion induced an identical tachycardia. The tachycardia started after a normally conducted atrial extrastimulus followed by ventriculo-atrial dissociation and it was possible to overdrive with atrial pacing. The tachycardia could not be reinduced after treatment with atenolol and the patient is asymptomatic 12 months later. These reports show that it is possible to study certain ventricular tachycardias by transesophageal atrial pacing. The efficacy of antiarrhythmic therapy can be controlled simply by this non-invasive technique.

[Spatial ventricular gradient studied by computerized vectorcardiography. Normal and pathological values. Interpretation and clinical evaluation]. / Le gradient ventriculaire spatial étudié par vectocardiographie informatisée. Valeurs normales et pathologiques. Essai d'interprétation et d'évaluation clinique.

The ventricular gradient is a reflection of uneven ventricular repolarisation. Until recently is was only appreciated in the frontal plane of the classical electrocardiogramme and expressed as the sum of the vectors representing the surfaces under the QRS complex and T wave. We used computerised vectorcardiography to obtain a more exact evaluation of the size and spatial orientation of the vector gradient. The spatial vector gradient was calculated in a control group and in a number of pathological conditions. The reference values were established in 70 normal subjects with a mean age of 36 +/- 21 years: 0.092 +/- 0.016 m V.s for amplitude: 38.4 degrees +/- 6.1 for thesite and 21.6 degrees +/- 8.7 for the azimuth. The size and spatial orientation of the ventricular gradient can be used to define normal limits and to distinguish subgroups by using the values of the site and azimuth. The spatial ventricular gradient is a new approach to defining the limits of normality in poorly understood abnormalities of ventricular repolarisation. It may also be useful in the comprehension of certain forms of cardiac arrhythmia related to desynchronisation of ventricular repolarisation.

[Von Willebrand factor in coronary disease]. / Le facteur de Willebrand en pathologie coronaire.

The value of studying factors of haemostasis and thrombosis in patients with coronary artery disease is established. The endothelial lesion and evolution of the thrombus play key roles in acute coronary syndromes and coronary angioplasty. The von Willebrand factor (VWF) is known for its participation in primary haemostasis. Deficits of this factor lead to a haemorrhagic syndrome, von Willebrand's disease. This glycoprotein is mainly synthesised by the endothelial cells. Its polymeric composition allows identification of two types of multimeres. The high molecular weight, active multimeres are liberated from the endothelium after stimulation by thrombin. Low molecular weight multimeres are less active and are secreted continuously. The VWF promotes platelet adhesion and facilitates platelet aggregation. Experimental pig models with VWF deficiency show that this factor is essential for the constitution of an occlusive thrombus. Several physiopathological mechanisms interact to increase VWF concentrations during thrombosis: the endothelial lesion, adrenergic stimulation, acute phase reaction. Increased VWF concentrations have been reported in many clinical situations. The results are most demonstrative in coronary artery disease. The VWF is abnormally high from the time of hospital admission in patients with acute myocardial infarction and continues to increase up to the 5th day before falling, without returning to normal values, at the 15th day. It is a sensitive though not specific late diagnostic marker of myocardial infarction. Increased VWF concentrations are not proportional to the severity of coronary atherosclerosis. They are, however, related to the infarct size, to the inflammatory reaction and to the prothrombotic phase.(ABSTRACT TRUNCATED AT 250 WORDS)

[Acute myocardial infarction: immediate coronary angioplasty for failure or contra-indications of thrombolytic therapy. Apropos of a series of 100 cases]. / Infarctus myocardique aigu: angioplastie coronaire immédiate en cas d'échec ou de contre-indication la thrombolyse. A propos d'une série de 100 cas.

One hundred patients admitted to a centre of interventional cardiology with acute myocardial infarction of less than 6 hours, underwent coronary angioplasty of first intention because of contra-indications to thrombolytic therapy (n = 20) or after thrombolytic therapy with streptokinase (n = 54), acylenzymes (n = 12) or tissue type plasminogen activator (n = 14). The indication of angioplasty were those of the TIMI (Thrombolysis in Myocardial Infarction) classification (occluded artery, TIMI grade 0) (n = 60) (suboccluded artery, TIMI grade 1) (n = 40). The criterion of success of angioplasty was an increase greater than 1 of TIMI grade. Reperfusion of the coronary artery was obtained by angioplasty in 95% of failures of thrombolysis and in 90% of patients with contra-indications to thrombolytic therapy. The early reocclusion rate at D1 was 2%. Repeat angioplasty at D1 was successful in both these cases and the arteries were still patent at D21. The reocclusion rate at the third week in 75 patients who underwent control coronary angiography was 5.3%. In patients with arterial occlusion, immediate angioplasty attained two objectives in the same procedure: a high rate of emergency myocardial reperfusion and a low rate of reocclusion. The average left ventricular ejection fraction (all arteries) significantly improved (+9.2% in absolute values) when the artery remained patent (p less than 0.001), especially when the initial ejection fraction was low. In the patients who had occluded arteries at control angiography at 3 weeks, the ejection fraction decreased (-4% in absolute values) (NS). The following complications were observed: 4 coronary artery dissections and haematomas at the site of femoral puncture in patients who had received thrombolytic therapy (10 drained surgically). The hospital mortality was 3% and global mortality after an average follow-up period of 19.6 months was 5%. Coronary angioplasty in acute myocardial infarction carries a low risk and seems to be beneficial in patients with contra-indications to or failure of thrombolysis.

[Effects of heart rate increase by transesophageal stimulation on the left ventricular filling in the normal subject. A pulsed echo-Doppler study]. / Effets de l'accroissement de la fréquence cardiaque par stimulation transoesophagienne sur le remplissage ventriculaire gauche chez le sujet normal. Etude par écho-Doppler pulsé.

The effects of increasing the heart rate on left ventricular filling were studied by Doppler echocardiography in 12 mildly sedated normal subjects. The heart rate was increased by 10, 20 and 30 bpm with respect to the basal rhythm by transoesophageal pacing. Four stages were thereby defined: S0, S1, S2 and S3. The principal results were: absence of variation of the isovolumic relaxation period in absolute values (92 +/- 14, 86 +/- 16, 87 +/- 16, 78 +/- 11 ms); absence of variation of the duration of the rapid filling period (246 +/- 36 at 50 vs 220 +/- 28 ms at 53); no change in peak filling velocity (72 +/- 11 at 50 vs 61 +/- 11 ms at 53) or in the timing of peak velocity (77 +/- 12 at 50 vs 72 +/- 13 ms at 53); increased contribution of atrial systole during tachycardia (Vmax 43 +/- 7 at 50 vs 76 +/- 17 cm/s at 53). Therefore, of these Doppler echo parameters, only atrial systole changed during the range of tachycardia rates which were studied. Its increase compensated the loss of diastolic diastasis. These changes should be born in mind in Doppler echocardiographic studies of left ventricular diastolic function.

[Congestive heart failure with intact systolic function]. / Insuffisance cardiaque congestive à fonction systolique conservée.

A retrospective study was undertaken of the cases of patients admitted for congestive cardiac failure over a 4 year period, and investigated by radionuclide angiography to determine the prevalence of cardiac failure with normal left ventricular systolic function, to document the underlying mechanisms of this condition and to assess whether the clinical data could predict the presence or absence of left ventricular systolic dysfunction. After excluding patients with significant valvular disease, severe renal failure, or myocardial infarction in the previous 2 months, the study population comprised 152 patients divided into 2 groups: Group I (N = 112) with abnormal systolic function (radionuclide ejection fraction less than 45%) and Group II (N = 40) with normal systolic function (radionuclide ejection fraction greater than or equal to 45%). The clinical, echocardiographic and radionuclide angiographic data was analysed (global ejection fraction in both groups and peak filling rate in Group II). The patients in Group II (26% of the total study population) were older (66.5 +/- 12.4 vs 61.3 +/- 12.3 years, p less than or equal to 0.02), were more often female (35% vs 17.9%, p less than or equal to 0.02), had acute cardiac failure (75% vs 37%, p less than 0.00001), and were frequently hypertensive (65% vs 39%, p less than or equal to 0.005). Univariate analysis of clinical and radiological signs did not show any significant difference between the two groups except for increased jugular venous pressure and cardiomegaly which were more common in Group I (56% vs 25%, p less than 0.00001 and 93% vs 68%, p less than or equal to 0.00001, respectively).(ABSTRACT TRUNCATED AT 250 WORDS)

[Isolated ST segment depression from V2 to V4 leads, an early electrocardiographic sign of posterior myocardial infarction]. / Le sous-décalage isolé du segment ST de V2 à V4, un signe électrocardiographique précoce d'infarctus du myocarde postérieur.

ST segment depression in leads V2 to V4 in a clinical and biochemical context of myocardial infarction is usually interpreted as a sign of non-Q wave anterior walls infarction. In order to determine if this clinical electric entity could indicate transmural posterior or posterolateral infarction, as recently suggested, we undertook a prospective study of 328 primary myocardial infarctions. Isolated ST depression in leads V2 to V4 was observed in 28 patients (8.5%). It was maximal in V3 (1.8 +/- 0.7 mm) or V4 (2 +/- 1 mm). The T wave was always positive. All these case had segmental wall motion abnormalities of the left ventricular posterolateral wall on 2D echocardiography. The Q wave confirming the transmural character of the infarct was observed in leads V7, V8 and V9 on average 33 hours after the onset of pain (10-56 hours) as did the increase in the R/S ratio in leads V1 and V2. Coronary angiography performed in 26 patients showed significant disease of the left circumflex artery in all cases. This was isolated (39%) or associated with left anterior descending (15%), right coronary artery disease (19%) or both (27%). In conclusion, isolated ST segment depression in leads V2-V4 in the clinical context of acute myocardial infarction indicates a transmural posterior localisation of the necrosis. It corresponds to reciprocal subepicardial posterior ischaemia. In cases of inferior infarction, it reflects postero-lateral extension rather than associated anterior wall ischemia.

[Value of cine magnetic resonance imaging in the diagnosis and quantification of valvular regurgitation. Comparison with angiography and Doppler echocardiography]. / Valeur du ciné-IRM dans le diagnostic et la quantification des fuites valvulaires. Comparaison avec l'angiographie et l'échocardiographie doppler.

Thirty-three patients presenting with regurgitation of the mitral valve (19 cases), tricuspid valve (14 cases) or aortic valve (11 cases) documented by angiography (n = 20) and/or doppler-echocardiography (n = 28) were examined by cine-MRI in order to test this method in valvular regurgitation. Sixteen ECG-synchronized cine-MRI images were acquired by the GRASS technique every 40 ms on appropriate projections, with a resistive 0.28 Tesla Bruker magnet. The semiology of normal and pathological blood flow images at cine-MRI is described. Valvular regurgitations present as "signal void" jets the chronology and spatial extension of which depend on the severity of the lesion. The differential diagnosis with physiological flows is discussed. The diagnostic sensitivity of the method was 29/29 when compared with angiography and 29/33 when compared with doppler-echocardiography (2 cases of 1/4 mitral regurgitation and 2 cases 1/4 tricuspid regurgitation were not visible at cine-MRI). The specificity of this method, as can be judged from 104 patients explored, also seems to be satisfactory. The severity of regurgitation was graded from 1 to 4 with the three methods, on the basis of strict criteria. The differences in grade evaluation exceeded +/- 1 point in only one case of mitral regurgitation which was greatly underestimated by the doppler method as compared with angiography and cine-MRI. Thus, cine-MRI is a reliable method to evaluate valvular regurgitations and their severity. It solves the practical problem raised by non-echogenic patients when catheterization is to be postponed or avoided.