Characterization of different subsets of atrial fibrillation in general practice in France: the ALFA study. The College of French Cardiologists.

BACKGROUND: The clinical presentation and causes of atrial fibrillation (AF) in the 1990s may differ from AF seen 2 to 3 decades ago. It was the objective of this prospective study to characterize various clinical presentations and underlying conditions of patients with AF observed in general practice in France. METHODS AND RESULTS: The study population comprised 756 patients (19 to 95 years of age) with electrocardiographically documented AF subdivided into paroxysmal (<7 days), chronic (last episode >1 month) and recent onset AF(persistent >7 days and<1 month). Symptoms were present in 670 patients (88.6%). The relative prevalences of paroxysmal, chronic, and recent onset AF were 22.1%, 51.4%, and 26.4%, respectively. Cardiac disorders, present in 534 patients (70.6%), included hypertension (39.4%), coronary artery disease (16.6%), and myocardial diseases (15.3%) as the most common. Rheumatic valvular disease represented a common cause in women (25. 0%) but not in men (8.0%). The paroxysmal group differed by a high percentage of palpitations (79.0%) and a low percentage of underlying heart disease (53.9%). With a mean follow-up of 8.6+/-3.7 months, 28 patients (3.7%) died, including 6 fatal cerebrovascular accidents. Among the 728 patients who survived, congestive heart failure occurred in 30 patients (4.1%), and embolic complications occurred in 13 patients (1.8%). In the paroxysmal AF group, 13 patients (8.0%) developed chronic AF and 51 (31.3%) had AF recurrences. At the time of follow-up, 53 patients (14.3%) from the chronic AF group and 108 patients (55.7%) from the recent onset AF group were in sinus rhythm. CONCLUSIONS: This large-scale study establishes the current demographic profile of out-of-hospital patients with AF and highlights some of the changes that have occurred in the past decades, including a particular shift in cardiac causes toward nonrheumatic AF. This study also demonstrates significant differences between various subsets of AF.

Holter monitoring in the complex analysis of sinus node dysfunction.

To study the diagnostic possibility and the mechanisms involved in sinus node dysfunction, 23 patients with sick sinus syndrome were evaluated by the basic electrophysiological method (recovery times, secondary postpacing phases, sinoatrial conduction times) before and after pharmacologic autonomic blockade with i.v. propranolol 0.2 mg/kg and atropine 0.04 mg/kg, and by continuous rhythm monitoring. Patient groups of normal (I) and pathological (II) intrinsic heart rate (IHR) were compared. In group I (no. 15) prolonged recovery time (2/15), postpacing sinoatrial-block (1/15) and chaotic postextrasystolic patterns (5/15) ceased after autonomic blockade; we obtained normal intrinsic recovery time, gradual return to the stable intrinsic sinus cycle length in the secondary phase, and a normal intrinsic sinoatrial conduction time. In group II (no. 8) during the control study only 50% of patients had pathological electrophysiological parameters before, and 100% after the drug test (no gradual postpacing return to the intrinsic heart rate, abnormal recovery times, abnormal sinoatrial conduction times or chaotic postextrasystolic patterns). Holter monitoring revealed significant differences between the minimal heart rate during sleeping (group I: 48 +/- 10 bpm, mean +/- SD group II: 32 +/- 4 bpm, probability less than 0.001) as well as in the average sinus cycle length for 24 hours (group I: 848 +/- 88 ms, group II: 1254 +/- 136 ms, P less than 0.001) with a very characteristic histogram. In the patients with pharmacologically and electrophysiologically documented abnormal intrinsic rhythmicity (group II), the first 24 hour Holter monitoring revealed positive ECGs for sinus node dysfunction. In patients with normal intrinsic electrophysiological sinus node properties (group I) repeated continuous rhythm recordings revealed severe sinus bradycardia (1 patient), sinoatrial-block (1 patient), tachybrady syndrome (1 patient) and sinus-arrest (2 patients, up to 29 120 ms in waking period). These findings suggest that 1) IHR is the best and simplest diagnostic method of intrinsic sinus node dysfunction (in patients of abnormal low IHR we found positive electrophysiological and Holter parameters), and 2) in autonomic sinus node dysfunction electrophysiological parameters are essentially negative showing normal intrinsic sinus node function; in these patients systematically repeated Holter monitoring is the most valuable diagnostic method.

Synchronized and desynchronized sinus node activity.

In certain cases because of sinus arrhythmia and/or anarchic return and postreturn cycles caused by premature atrial stimulation, the sinoatrial conduction time cannot be calculated since a chaotic postextrasystolic pattern appears. We examined 49 patients with a history and ECG signs suggesting sinus node dysfunction by programmed extrastimulation method as proposed by Strauss et al. prior to and after pharmacologic autonomic blockade (with propranolol 0.2 mg/kg body weight and atropine sulfate 0.04 mg/kg intravenously). Patients with normal intrinsic heart rate (IHR) (n = 31) showed chaotic postextrasystolic responses in 38%, which in every case could be eliminated by autonomic blockade, resulting in a clear I and II phase with a well estimated intrinsic conduction time. Patients with pathologic IHR (n = 18) gave chaotic responses in 22% which after drug testing increased up to 72%. The chaotic postextrasystolic patterns are to be interpreted as the desynchronization of the sinus potentials, while plateau (phase II) as functional integrity, synchronized activity of the sinus node, dependent on the momentaneous balance of the autonomous tone, and on the integrity of the pacemaker cells. The desynchronized chaotic responses are considered on one hand as a dystonic neurovegetative electrophysiologic characteristic, on the other hand as a primary extrastimulation parameter of the intrinsic sinus node dysfunction.

[Significance of pharmacodynamics tests in the study of sinus node function]. / Intérêt des épreuves pharmacodynamiques dans l'étude de la fonction sinusale

The evaluation of sinus function in man rests upon atrial stimulation techniques (rapid atrial stimulation, premature atrial stimulation); in a certain number of cases the results are inconclusive. There are various pharmaco-dynamic tests which can be used in such cases, the aim being to stimulate or depress the function of the sinus, or alternatively to modify the action of the extrinsic nerve supply. A study was carried out of sinus function in a series of 120 patients; pharmaco-dynamic tests were carried out using atropine in 43 cases, glucagon in 9 cases, isoproterinol in 9 cases, ajmaline in 9 cases, and piprofurol in 10 cases. The authors conclude from this study that it is worth adding the atropine test (which suppresses vagal tone), the glucagon test (which causes direct and limited stimulation of the sinus) and a test with an agent with a depressant action on the sinus coupled with a sympathetic-blocking action (such as piprofurol) to the conventional atrial stimulation tests.

[Effect of a depressant drug on the recovery time of the sinus. Attempt of application to the diagnosis of sinus dysfunctions]. / Effet d'une drogue dépressive sur le temps de récupération sinusal. Essai d'application au diagnostic des dysfonctionnements sinusaux.

The authors have studied the effect of a depressant drug, 71247 or piprofurol, on the recovery time of the sinoatrial node after rapid electrical stimulation of the atrium (CSRT). 72 patients, divided into three groups, underwent the test: 14 patients with documentary evidence of sinus dysfunction; 48 patients in whom a sinus disorder was suspected, and 10 controls. As a general rule, the sinus recovery time was found to be significantly prolonged in the patients as compared with the controls. The authors have applied this test to the diagnosis of latent sinus dysfunction, categorising three different degress of RESA values: normal (less than or equal to 550 ms), average (between 550 and 1,000 ms), and prolonged (greater than 1,000 ms). In 6 patients from group one and seven from group two, the post-stimulatory pause was normal or average before the test, and prolonged after the injection of 71247; on the other hand the test did not give evidence of any prolongation of the pause in the controls. In this way a dynamic pharmacological test of depression brings and interesting slant on the diagnosis of disorders of the sinus.

[National survey on cardiovascular emergencies. Modalities of admission to cardiologic intensive care units (Paris excluded)]. / Enquête nationale sur les urgences cardio-vasculaires. Modalités d'admission en unité de soins intensifs cardiologiques (à l'exclusion de Paris).

In a national investigation carried out between December 10, 1985 and March 31, 1986, the modalities of admission of 19 Cardiology Intensive Care Units (Paris excluded) of 738 cardiovascular emergency patients were evaluated. Detail of the pre-medical phase duration and of the dispatching phase duration was obtained for each patient. Each of these two phases was then analyzed according to the geographical location of the Intensive Care Unit (ICU), to the symptoms experienced by the patient, to the type of medical aid initially sought (general practitioner, cardiologist, "emergency doctor") and to the medical itinerary followed. The median duration of the pre-medical phase was 1 h 45 min, that of the dispatching phase 2 h, 15 min and that of the total time elapsed before admission 5 hours, there being no clear-cut differences due to the location of the ICU. The duration of the pre-medical phase was essentially determined by the awareness of a vital risk or otherwise, or by the relation established by the patient between his symptoms and a possible heart disease. The median duration of the dispatching phase was about 2 hours when only one doctor intervened and 4 h, 35 min when a second doctor was consulted. The role of the cardiologist in the dispatching of these cardiovascular emergency cases was very limited (7 p. 100 of the patients) and not very expeditive, the median duration of admission being 6 h, 30 min when he intervened initially and 12 hours when he intervened at the request of the patient's general practitioner.(ABSTRACT TRUNCATED AT 250 WORDS)

[Preliminary study of a double chamber pacemaker with diagnostic function]. / Etude préliminaire d'un stimulateur double chambre à fonction diagnostique.

Pacemakers with diagnostic functions have been implanted for several years. The main clinical indication for these devices is unexplained syncope. Some reports of the use of diagnostic pacemakers have shown that in patients with unexplained syncope, paroxysmal bradycardia was a common finding after implantation. Until recently, diagnostic functions were only available in VVI pacemakers, which explains the limitations of this type of function in determining the mechanism of the bradycardia. The aim of this study was to assess a new dual-chamber diagnostic pacemaker functioning in the VDI mode. Twenty-three patients were implanted with this type of unit and followed up for an average of 153 days. The number of episodes of bradycardia detected was 6 +/- 10 (median: 3). The interval between the installation of the algorithm and the date of the first episode of bradycardia was 67 +/- 86 days (range: 12-306 days). The mechanisms of the bradycardia were atrioventricular block (6 patients), sinus node dysfunction (6 patients) and blocked atrial bigeminy in 1 patient. These conclusions were drawn from analysis of chains of markers. Bradycardia was recorded during the day or during the day and night in 21 patients; bradycardia was exclusively nocturnal in only 2 patients. The tolerance of the algorithm was good on the whole but 3 patients reported minor symptoms related to the relative bradycardia inherent with this type of algorithm. Four other patients had a VDI pacemaker syndrome which was completely corrected by reprogramming the pacemaker to the standard DDD mode. These new devices represent a technical advance in the field of diagnostic pacemakers.(ABSTRACT TRUNCATED AT 250 WORDS)

[Nosology of atrial fibrillation. Attempt at clarification]. / Nosologie de la fibrillation auriculaire. Essai de clarification.

Atrial fibrillation is the subject of much clinical interest as it is the arrhythmia responsible for the greatest number of hospital admissions. The arrhythmia working group of the French Society of Cardiology held a symposium on atrial fibrillation in order to establish certain definitions and to assess the value of a classification of atrial fibrillation. This was also the occasion to review a number of known facts and points which remain obscure, concerning this common arrhythmia. A therapeutic strategy is proposed.

[Exclusive permanent atrial stimulation. Clinical experience apropos of 65 cases with a follow-up of 1 to 5 years]. / Stimulation auriculaire permanente exclusive. Expérience clinique à propos de 65 observations avec un recul de 1 à 5 ans.

The authors report their experience of permanent exclusive atrial pacing in the treatment of sinus node dysfunction in a series of 65 cases with a follow up of 1 to 5 years (average 37.6 months; 2406 patients months), 41 women and 24 men aged 74 +/- 3 years. Sixty one patients were symptomatic. The diagnosis was made from surface ECG recordings in 54 cases (83 p. 100) and after electrophysiological investigation in 11 cases (16 p. 100). Atrioventricular conduction was carefully evaluated before implantation: PR equal to or less than 200 ms, Wenckebach point equal to or greater than 130/min, absence of ventricular pauses longer than 3,000 ms after carotid sinus massage, HV interval equal to or less than 55 ms [measured in 57 cases (87 p. 100)], negative Ajmaline test in 6 patients with intraventricular conduction defects. Performed J-shaped atrial leads with active (66 p. 100) or passive fixations (34 p. 100) were implanted by an endocavitary approach (right subclavian vein in 60 cases: 92 p. 100). There were 3 cases of early lead displacement and one patient developed an elevated threshold of pacing. There were 5 deaths during the follow-up period (3 of cardiovascular origin). The neurological symptoms disappeared in 93 p. 100 of cases. No cases of cardiac failure were observed after permanent pacing. Fifteen patients had documented supraventricular arrhythmias before implantation; 5 patients continued to have the same paroxysmal or permanent arrhythmias but 10 patients had no further recurrences, 8 with and 2 without antiarrhythmic therapy.(ABSTRACT TRUNCATED AT 250 WORDS)

[Study of sinus node function. Preliminary results]. / Etude de la fonction sinusale. Résultats préliminaires

Direct exploration of the sinus node remains experimental. Indirect techniques have been put forward to assess the sinus function in man: high frequency atrial pacing; premature atrial pacing; pharmacodynamic tests using atropin and isoproterenol injection. 68 patients were so explored: in 10 of them were ECG signs suggestive of "sinus disease" or "atrium disease" (group I); 14 subjects had only a sinus bradycardia with a rate of 55/mn or below (group II); in 16 cases, the ECG tracing was normal, but there was the notion of paroxysmal tachycardia or various disturbances (group IIIa); finally, in 28 cases the ECG demonstrated atrio-ventricular or inter-ventricular conduction disturbances (group IIIb). The preliminary results reported here should be interpreted carefully; nevertheless, correlation of the data obtained by the various techniques used, seems to be able to allow a correct assessment of sinus automatism, and of sino-atrial conduction.

[Sinus dysfunction and nodo-hisian conductive disorders. Indication for definitive cardiac stimulation]. / Dysfonctionnement sinusal et troubles conductifs nodo-hisiens. Indications de la stimulation cardiaque définitive.

A consecutive series of 80 patients has been the object of intracavitary electrophysiological studies, including a study of sinus function and of node/His conduction, before implantation of a definitive cardiac pacemaker. Investigation of the sinus yielded normal or insignificant results in 32 cases. It revealed certain criteria of "major" sinus dysfunction (TRSC 1000 ms; more than compensatory return cycles where there was SAP) in 39 cases, made up of 18/20 in group I (documented evidence of sinus malfunction), 10/14 in group II (sinus bradycardia less than or equal to 55/mn), 9/44 in group III (A-V conduction defects), and 2/2 in group IV (paroxysmal supraventricular tachycardia); criteria of "minor" sinus dysfunction (TRSC between 550 and 1000 ms, TECASA greater than 210 ms) were found in only 9 cases (group I--1; group II--2, group III--6). The association of sinus malfunction with node/His conduction defects was found in 29 cases, the site of the AV block being nodal in 7 cases, intra-His in 2 cases, infra-His in 10 cases, and a combination of nodal and infra-nodal in 10 cases. In 59 cases, the severity of the AV block (40 cases), of the sinus malfunction (17 cases) or of the sinus bradycardia (2 cases) was already obvious, and investigation of the sinus was not critical in determining the indications for a cardiac pacemaker. In 21 cases, however, this investigation was a determining factor, and most especially in 12 cases from group II. Sinus investigation seems to represent, in addition, a valuable indicator for the decision to install a pacemaker in a certain number of litigious cases.

[Clinical study of double-chamber stimulation. Apropos of 50 cases followed-up for 1 to 5 years]. / Etude clinique de la stimulation double chambre. A propos de 50 observations avec un suivi de 1 à 5 ans.

The authors report their experience of dual chamber pacing in 29 men and 21 women of mean age 71 +/- 4 years. 35 had sinus node dysfunction associated with node-His bundle conduction disorders; 31 presented with neurological symptoms and 4 with heart failure (due to pacemaker syndrome in 1 case). Sinus node dysfunction was diagnosed by surface ECG in 25 cases and after electrophysiological studied in only 10 cases. Fifteen patients had atrioventricular block without sinus node dysfunction: 2 of them were young subjects, 1 had pacemaker syndrome and 12 were actual or potential heart failure patients for whom preservation of the atrial systole was justified. Nine patients presented with neurological symptoms. 43 (86%) had cardiac or arterial disease associated with cardiac rhythm and conduction disorders. The percutaneous single subclavian vein approach was used in 36 cases (78%). 41 active and 9 passive fixation electrodes were utilized. The mean follow-up period was 25 months (12 to 70 months), with a cumulative figure of 1,253 months/patients. Two late re-operations for displacement of the atrial electrode were performed. Dual chamber pacing was abandoned, 14 months on average after implantation, in 9 patients (18%), on account of arrhythmias in 4 of them. Three cases of tachycardia from "electronic re-entry" and 6 cases of supraventricular arrhythmia transferred to the ventricle by the pacemaker were observed. Sixteen patients (32%) died 12 +/- 4 months on average after surgery: 12 (33%) had sinus node dysfunction and 4 (26%) had AV block. Death was caused by a cardiovascular disease in 12 cases.(ABSTRACT TRUNCATED AT 250 WORDS)

[Gap phenomenon and supranormal conduction during intermittent left bundle-branch block]. / Phénomène de Gap et conduction supernormale au cours du bloc de branche gauche intermittent

The mechanism of intermittent bundle branch block, whether spontaneous or as a result of vagal stimulation, can be studied by reference to the known facts of atrial stimulation. Three cases with intermittent left bundle branch block were studied by means of an intracavitary electrode, which allowed the potential of the bundle of His to be measured, and was also used for the extrastimulus method of study. In case 1, in which the block was independent of the cardiac rate, a type 1 "Gap" phenomenon (of nodal origin) was demonstrated; the coupling zone in which the extrastimulus overcame the block was situated in two areas, one being late, and the other earlier in a region where the conduction was normal. In case 2, in which the block was dependent upon the heart rate, the "recovery" of the blocked branch after early coupling of the extrastimulus seemed to be associated with the phenomenon of "supra-normal" conduction. In case 3, in which the block was again dependent upon heart rate, the two phenomena of "Gap" and "suppranormality" seemed to act successively when the coupling of the extrastimulus is decreased progressively. These observations allow us to distinguish two types of intermittent left bundle branch block; one, which is not related to heart rate, is characterised by a prolonged refractory period of the left bundle branch, which becomes progressively shorter as the heart rate increases; the other, which is dependent upon tachycardia, is characterised on the one hand by an increased left bundle branch refractory period which does not shorten as the heart rate increases, and on the other by the phenomenon of supranormal conduction.

[Course of ventricular arrhythmias following myocardial infarction. Results of a 2-year follow-up]. / Evolution des arythmies ventriculaires après infarctus myocardique. Résultats d'un suivi de deux ans.

The incidence, evolution and prognostic significance of ventricular arrhythmias after myocardial infarctions were studied over a 2 year period in 144 patients (108 men, 36 women: mean age 64 +/- 2 years) by Holter monitoring on the 20th day, 6th month (104 recordings), 12th month (94 recordings), 18th month (76 recordings) and 24th month (82 recordings). A total of 500 recordings was obtained, 471 of which were of good enough quality to be interpreted. On the 20th day, the prevalence of ventricular arrhythmias was independent of the site of myocardial infarction: they were classified as follows (Lown and Wolff grading): no ventricular arrhythmias (34 patients); moderate (Grade I) arrhythmias (73 patients, 50%); severe ventricular arrhythmias (Grades 2, 3, 4, 5) (37 patients, 26%). Fourty-seven patients underwent all 5 Holter recordings, the evolution of the arrhythmias could therefore be followed in detail. Despite considerable individual variation, the overall evolution indicated a clear aggravation at 6 months compared to the recording taken on the 20th day. At the 12th month, there was a higher incidence of arrhythmias but they were of a lower grade in 72% of cases: there was a steady improvement thereafter until the 24th month with the incidences falling to those observed on the 20th day. At the end of 2 years, there were 102 survivors; 41 patients died, and one was lost to follow-up. Over half the deaths (23 cases) occurred during the first 6 months, 4 during the second, 7 during the third and 7 during the fourth 6 months. The cause of death was cardiac in 21 cases, was of other causes in 4 cases and was unknown in 16 cases. The correlation between the death rate and results of Holter monitoring on the 20th day showed: only 4 of the 41 deaths had no recorded ventricular arrhythmia, there was a moderate or severe ventricular arrhythmia in 37 cases; in these patients, the cause of death (cardiac or other) was not related to the degree of arrhythmia. These results confirm previously reported preliminary studies indicating the value of Holter monitoring on the 20th day of myocardial infarction for assessing the 2 year prognosis. Death occurred in I ou of 10 Patients without ventricular arrhythmias, in 1 out of 4 patients with a moderate ventricular arrhythmia, and in 1 out of 2 patients with severe arrhythmias (p less than 0.001). The evolution was characterised by a "critical period", the first year, during which most deaths and aggravation of ventricular arrhythmias (in survivors) were observed; during the second year, there was a progressive improvement.(ABSTRACT TRUNCATED AT 400 WORDS)

[Sinus node dysfunction. Clinical outcome and results of cardiac pacing]. / Dysfonctionnement du noeud sinusal. Evolution et résultats de la stimulation cardiaque.

112 patients (average age 66 +/- 13 years) with sinus node dysfunction, selected on clinical, electrocardiographic and electrophysiological criteria, were followed up for a period of 3 to 55 months (average: 30,2 months). Permanent cardiac pacing was instituted in 59 patients (52,6 p. 100), and the remaining patients treated medically. 25 patients were lost to follow up (22,3 p. 100: 5 paced, 20 non paced). 16 patients died (14,2 p. 100): mortality was relatively early (average 11,7 months) and higher in patients with pacemakers (15/16); the causes of death were acute heart failure (8 cases), and cerebral vascular accident (3 cases). In the surviving paced patients neurological symptoms completely regressed. In this series, the life expectancy of patients with sinus node dysfunction seemed to depend mainly on the state of their myocardium, but the functional prognosis was clearly improved by cardiac pacing.

[Syncope and transient neurologic deficits of undetermined origin. Clinical and electrophysiological correlations]. / Syncopes et déficits neurologiques brefs d'origine indéterminée. Corrélations cliniques et électrophysiologiques.

A consecutive series of 140 patients who presented either with syncope or transient neurological deficit of undertermined cause underwent electrophysiological investigation. The patients were classified in 3 groups: Group I comprising 55 patients having presented "true syncope"; Group II comprising 42 patients with "false vertigo"; and Group III comprising 43 patients in whom a transient neurological deficit had been observed. Globally, the investigations were positive in 58 patients (41,4%). Paroxysmal atrioventricular block was recorded in 21 cases (15%), sinus node dysfunction in 34 cases (2,1%). Permanent pacing was instituted in 57 patients. The correlation between the results of electrophysiological investigation and the clinical symptomatology showed a highly significant difference between Groups I and II where the results were positive in 57% cases, and Groupe III where 93% of the investigations were negative.

[Cardiology in general hospitals. A cooperative survey on medical teams, technical means and activity]. / La cardiologie en hôpital général. Enquête coopérative sur les équipes médicales, les moyens techniques et l'activité.

A national enquiry carried out in 1990 in the departments of cardiology of general and private non-profit making hospitals established the status of these departments and the evolution of their personnel and equipment since their creation. The enquiry involved two thirds of the cardiology departments of the general hospitals (119/180) and showed that most (66%) were established between 1974 and 1988. Implanted in fairly important cities with catchment areas of 100,000 to 400,000 people, they have an average of 32 beds (range 11 to 100) and 7.25 coronary care beds (range 4 to 19); 347 doctors work full (211) or part time (136) in these departments. These two types of work are allowed in the majority of these units (64/119). Specialist certified cardiologists practice in 62 departments (56%). The usual technical equipment is available in 80% of the units (Doppler echocardiography, exercise stress testing, Holter monitoring, right heart catheterisation). Permanent pacing is performed in 65% of these hospitals, more so in the provinces than in the Paris region. Coronary angiography is only available in 21%, radioisotopic investigations in 15% and coronary angioplasty in 12% of these centres. A prospective study performed in 1990 concerning 110 hospitals recruited 1,030 myocardial infarctions, which enabled the total number of infarcts hospitalised in the coronary care units of the general hospitals to be estimated at about 21,000 (60% of French myocardial infarctions).

[Bepridil in the treatment of supraventricular paroxysmal tachycardias]. / Le bépridil dans le traitement des tachycardies paroxystiques supraventriculaires.

Previous studies have demonstrated the efficacy of bepridil, a new calcium antagonist, in the treatment of ventricular extrasystoles and tachycardia. The electrophysiological properties of bepridil especially the lengthening of the atrial effective refractory period, would also suggest an antiarrhythmic effect at the supraventricular level. This effect was studied on 33 episodes of paroxysmal supraventricular tachycardia (SVT) occurring in 23 patients (6 men and 17 women, mean age 58.1 years; range 18 to 88 years). Bepridil was given intravenously over 5 minutes at a dose of 3 mg/kg. The duration of SVT before administration was less than 1 hour in 10 cases, between 1 and 2 hours in 8 cases and over 2 hours in 15 cases. Sinus rhythm was successfully restored in 25 cases: within 1 to 5 minutes in 19 cases, 6 to 10 minutes in 3 cases and 11 to 30 minutes in 3 cases. In 24 of the 25 cases sinus rhythm was restored without a prolonged pause (over 2 sec) after the termination of SVT; in 3 cases intermediary atrial fibrillation lasting 1, 3 and 9 minutes was observed. There were no side-effects in 26 cases; transient flushing was noted in 5 cases and vagal symptoms in 2 cases. Haemodynamic tolerance judged by blood pressure measurements excellent in all cases. The correlations between plasma concentrations of bepridil and success or failure were poor. In conclusion, bepridil is a valuable alternative to adenosine triphosphate which may induce an exaggerated vagal response and to verapamil whose negative inotropic effects may sometimes be a serious disadvantage in the reduction of paroxysmal SVT.

[Long-term prevention of the recurrence of auricular fibrillation using cibenzoline. Multicenter study apropos of 89 case reports]. / Prévention au long cours des récidives de fibrillation auriculaire par la cibenzoline. Etude multicentrique à propos de 89 observations.

The aim of this study was to evaluate the long-term efficacy of cibenzoline in preventing recurrence of atrial fibrillation compared to a reference drug: quinidine arabo-galactane sulfate (QAGS). The two products were administered orally in a double blind multicentre trial to two different groups of patients (96 patients in all) in whom atrial fibrillation had been previously converted to sinus rhythm after having been present for at least 15 days and less than 18 months. The patients were either given four 65 mg gelules of cibenzoline (group I) or four 206 mg gelules of Longacor (group II) and were reviewed systematically after 3 days of treatment, in order to retain only those who had not relapsed during the first 72 hours (89 patients: 42 in group I; 47 in group II). As Holter monitoring was not available in all centres, follow-up was assessed by conventional ECG during clinical examination after 2 weeks, 6 weeks, 3 months and 6 months. The results seem to indicate that cibenzoline was more effective at the 6th month (20% recurrence rate in group I compared to 43.2% in group II). This difference was significant especially at the end of the 2nd week of treatment (p less than 0.04); the number of recurrences did not differ significantly between the two groups thereafter. In general the clinical tolerance was good. Biochemical tests showed a greater increase in serum transaminases (SGOT) in the cibenzoline than in the QAGS group but this difference did not attain statistical significance. We conclude that at 6 months cibenzoline is more effective than QAGS in preventing recurrent atrial fibrillation.

[Comparative study of quinidine and disopyramide in the treatment of stable ventricular extrasystole]. / Etude comparée de la quinidine et du disopyramide dans le traitement des extrasystoles ventriculaires stables.

The antiarrhythmic efficiency of quinidine arabogalactan-sulphate (QAGS) and disopyramide were determined in 38 patients showing chronic, stable frequency premature ventricular beats (PVB). The study which was carried out in 4 medical Centers, used a longitudinal cross-over design. After a baseline evaluation which consisted of two 24 hours electrocardiograms, the patients were randomised to one of the two drugs during a period of 6 or 7 days. The drug sequence were followed by a placebo sequence. A 24 hours electrocardiogram was performed at the end of each sequence. The daily doses were equivalent to 660 mg of quinidine base for QAGS and 600 mg for disopyramide. Among the 38 patients who entered in the study, 32 went through each sequence of the test. The average number of PVB was significantly reduced by QAGS and disopyramide (p less than 0.0001). With QAGS 18 patients had more than 65 p. 100 reduction of PVB and 12 of them more than 80 p. 100. With disopyramide, 14 patients had more than 65 p. 100 reduction of PVB and 12 of them more than 80 p. 100. There was no statistical difference in the overall efficiency of the two drugs. Three patients died, one from myocardial reinfarction, one from ventricular fibrillation; in one other case, the cause of the death remained undetermined. QAGS was better tolerated than disopyramide; adverse effects occurred in 6 patients with QAGS and in 10 with disopyramide. The responsibility of disopyramide in the occurrence of two severe ventricular arrhythmia may be questioned.