Immune response to pertussis vaccine in COPD patients.

Exacerbation triggered by respiratory infection is an important cause of morbidity and mortality in chronic obstructive pulmonary disease (COPD) patients. Strategies aiming to preventing infection may have significant public health impact. Our previous study demonstrated decreased immunological response to seasonal flu vaccination in COPD patients, questioning the efficiency of other vaccines in this group of patients. We performed a prospective, monocenter, longitudinal study that evaluated the humoral and cellular responses upon pertussis vaccination. We included 13 patients with stable COPD and 8 healthy volunteers. No difference in circulating B and T cell subsets at baseline was noted. Both groups presented similar levels of TFH, plasmablasts and pertussis specific antibodies induction after vaccination. Moreover, monitoring T cell immunity after ex-vivo peptide stimulation revealed equivalent induction of functional and specific CD4+ T cells (IFNγ, TNFα and IL-2-expressing T cells) in both groups. Our results highlight the immunological efficiency of pertussis vaccination in this particularly vulnerable population and challenge the concept that COPD patients are less responsive to all immunization strategies. Healthcare providers should stress the necessity of decennial Tdap booster vaccination in COPD patients.

Relationship between achieved personalized glycaemic targets and monitoring of clinical events in elderly diabetic patients.

AIM: Recent guidelines for the management of type 2 diabetes (T2DM) in the elderly recommend adjusting the therapeutic target (HbA1c) according to the patient's health. Our study aimed to explore the association between achieving the recommended personalized HbA1c target and the occurrence of major clinical events under real-life conditions. METHODS: The T2DM S.AGES cohort was a prospective multicentre study into which 213 general practitioners recruited 983 non-institutionalized T2DM patients aged>65 years. The recommended personalized HbA1c targets were<7%, <8% and <9% for healthy, ill and very ill patients, respectively. Major clinical events (death from any cause, major vascular events and/or hospitalization) were recorded during the 3-year follow-up. Mixed-effects logistic regression models were used for the analyses. RESULTS: Of the 747 patients analyzed at baseline, 551 (76.8%) were at their recommended personalized HbA1c target. During follow-up, 391 patients (52.3%) experienced a major clinical event. Of the patients who did not achieve their personalized HbA1c target (compared with those who did), the risk (OR) of a major clinical event was 0.95 (95% CI: 0.69-1.31; P=0.76). The risk of death, major vascular event and hospitalization were 0.88 (95% CI: 0.40-1.94; P=0.75), 1.14 (95% CI: 0.7-1.83; P=0.59) and 0.84 (95% CI: 0.60-1.18; P=0.32), respectively. CONCLUSION: Over a 3-year follow-up period, our results showed no difference in risk of a major clinical event among patients, regardless of whether or not they achieved their personalized recommended HbA1c target. These results need to be confirmed before implementing a more permissive strategy for treating T2DM in elderly patients.

Therapeutic management in ambulatory elderly patients with atrial fibrillation: the S.AGES cohort.

UNLABELLED: Few epidemiologic studies have specifically focused on very old community dwelling population with atrial fibrillation (AF). The objectives of the AF-S.AGES cohort were to describe real-life therapeutic management of non-institutionalized elderly patients with AF according to age groups, i.e., 65-79 and ≥ 80 and to determine the main factors associated with anticoagulant treatment in both groups. METHODS: Observational study (N=1072) aged ≥ 65 years old, recruited by general practitioners. Characteristics of the sample were first evaluated in the overall sample and according to age (< 80 or ≥ 80 years) and to use of anticoagulant treatment at inclusion. Logistic models were used to analyze the determinants of anticoagulant prescription among age groups. RESULTS: Mean age was 78.0 (SD=6.5) years and 42% were ≥ 80 years. Nineteen percent had paroxysmal AF, 15% persistent, 56% permanent and 10% unknown type, 77% were treated with vitamin K antagonists (VKA), 17% with antiplatelet therapy with no differences between age groups. Rate-control drugs were more frequently used than rhythm-control drugs (55% vs. 37%, p < 0.001). VKA use was associated with permanent AF, younger age and cancer in patients ≥ 80 years old and with permanent AF and preserved functional autonomy in patients < 80 years old. Hemorrhagic scores were independently associated with non-use of VKA whereas thromboembolic scores were not associated with VKA use. CONCLUSIONS: In this elderly AF outpatient population, use of anticoagulant therapy was higher even after 80 years than in previous studies suggesting that recent international guidelines are better implemented in the elderly population.

The therapeutic management of chronic pain in ambulatory care patients aged 65 and over in France: the S.AGES Cohort. Baseline data.

OBJECTIVE: The main objective of the S.AGES (Elderly Subjects) cohort study is to describe the current therapeutic strategy for chronic pain in non-institutionalised elderly patients in France. METHODS: In this prospective cohort study, non-institutionalised patients aged 65 years and over with chronic pain were recruited by general practitioners (GP) across France. All medicinal and non- medicinal prescriptions were recorded at inclusion and will be followed up over 3 years via an eCRF. Data recorded at baseline are presented in this paper. RESULTS: Two hundred and sixty GPs enrolled 1379 evaluable patients between June 3rd, 2009 and June 3rd, 2011. Pain was mainly of a mechanical nature, due to osteoarthritis or common back pain. 80% of the patients had moderate or severe pain. More than a third of patients were treated with a step 1 analgesic (mainly paracetamol), and approximately 30% received a step 2 analgesic (23% dextropropoxyphene and 40.3% tramadol/paracetamol combination). Only 3% received step 3 analgesics; this rate remained low even in patients with severe pain. The proportion of patients treated with an antiepileptic was higher in case of neuropathic pain. More than 25% of patients did not receive any analgesic medication. CONCLUSION: The baseline S.AGES study results exhibit a well-balanced therapeutic management of chronic pain by GPs for ambulatory elderly patients. Clinicaltrials.org NCT01065909.

[Fabry disease among hypertrophic cardiomyopathy of genetic origin]. / Place de la maladie de Fabry au sein des cardiomyopathies hypertrophiques d'origine génétique.

Primary hypertrophic cardiomyopathy is a relatively frequent disease (1/500) which results from a mutation in a gene encoding a sarcomeric protein. In a series of 184 cases, nearly half (46 %) were secondary to a mutation in one of the 4 following genes : MYBPC3, MYH7, TNNI3, TNNT2. In Fabry disease, an exclusive or nearly exclusive cardiac expression is possible and referred to as "cardiac variant". The hypertrophic cardiomyopathy of Fabry disease is usually unspecific. Two series reported a prevalence of Fabry disease of about 6% among male cases. An Italian series of 34 female cases with hypertrophic cardiomyopathy demonstrated that it was feasible to diagnose Fabry disease in females by screening for specific lesions in myocardial biopsies. We detected a patient who initially presented with a common hypertrophic cardiomyopathy except that his ECG showed depression of ST segment and inversion of T wave in leads D1, VL and in precordial leads. The family history revealed several affected relatives and female carriers. In conclusion, an isolated common hypertrophic cardiomyopathy may be secondary to Fabry disease. Male patients should be screened systemically for enzyme defect except in cases of father-to-son transmission. In females, an affected male relative should be searched for screening or the GLA gene should be sequenced. It is important to think about a putative Fabry disease in cases with hypertrophic cardiomyopathy not associated with any obvious cause.

Choice of echocardiography method for postoperative evaluation of mitral valve replacement with a mechanical prosthesis.

OBJECT: The French Cardiology Society (SFC) systematically recommends (Class I) transesophageal echocardiography (TEE) after any mitral valve replacement with a mechanical prosthesis (MMVR). Taking into account the increasing workload of echocardiography laboratories, our attitude was to propose that only post-operative transthoracic echocardiography (TTE) is performed. The purpose of this study was to evaluate the possible risks of this simplified procedure. METHODS: We performed a precise analysis of one full year of practice of MMVR with exhaustive follow-up for the first 2 years concentrating on thromboembolic complications. RESULTS: From January to December 2003, 84 MMVRs (46 after rheumatic fever, 22 degenerative disease, 11 infective endocarditis (IE) and 5 ischemia) were conducted in 45 women and 39 men of average age 61 years. Early mortality (<30 days) concerned 5 patients (5.9%). A control TTE to determine normal prosthetic function was performed 7+/-2 days after surgery and this revealed 2 cases of nonobstructive thrombosis which were treated medically, 3 cases of paraprosthetic regurgitation, and 1 vegetation due to underlying IE. Actuarial survival was 90.5% at 1 year and 83.3% at 2 years. After a mean follow-up of 179.3 patient-years, 5 patients were reoperated (5.9%): 1 for IE, 1 for paravalvular regurgitation, 1 for mitral valve insufficiency with haemolysis, and 2 for obstructive prosthetic valve thromboses. In addition there were 2 cases of prosthetic valve thrombosis, 8 ischemic strokes (2 ministrokes, 6 sequelar strokes), and 1 peripheral embolism. The global thromboembolic complication rate was therefore 6.1 per 100 patient-years (n=11). There were 4 hemorrhagic events, i.e. a rate of 2.2 events per 100 patient-years. 63% of the 1193 INR conducted were within the target range (3-4.5), 26% were below 3 and 11% were greater than 4.5. 35% of patients with thromboembolic complications had an INR<3. CONCLUSION: Morbidity and mortality during the first 2 years after MMVR were relatively high but equivalent to the values of comparable series in the literature. These complications would not have been reduced by a more precise screening based on early TEE. Despite the increasingly litigious nature of the doctor-patient relationship, it would probably be excessive to oppose that this guideline was not followed in a dispute; in particular as it is difficult to apply this measure as echocardiography departments are overworked.

Assessment of myocardial ischemia and viability using tissue Doppler and deformation imaging: the lessons from the experimental studies.

Tissue Doppler imaging and strain rate imaging are quantitative methods for assessing myocardial function and have been shown to overcome the limitations of current ultrasound methods in assessing the complex changes in regional myocardial function that occur in differing ischemic substrates. Tissue Doppler imaging (TDI) measures in real time the myocardial velocity gradient which is an index of myocardial deformation. Strain and strain rate (SR) imaging has been shown to be a sensitive technique for quantifying regional myocardial deformation. Strain rate is less load-dependent that strain and provides therefore a better measure of contractility. In the setting of ischemia, experimental studies have shown that strain imaging was an accurate method for quantitative evaluation of regional myocardial function and may yield important physiological data. In myocardial infarction, transmural extension of scar distribution in the infarct zone is proportionally related to the reduction in systolic function measured by the radial transmural velocity gradient or by strain rate imaging. Measurement of both systolic and post-systolic deformation both at rest and during a graded dobutamine infusion may help to distinguish between transmural and non transmural infarcts. In conclusion, strain imaging has the ability to evaluate of regional myocardial function. Strain rate has not replaced conventional grey-scale imaging in the assessment of regional left ventricular function and the implement of these new indices in the routine clinical practice will need additional clinical and large-scale studies.

Preoperative tissue Doppler imaging differentiates beneficial from detrimental left ventricular hypertrophy in patients with surgical aortic stenosis. A postoperative morbidity study.

BACKGROUND: In a pressure overloaded left ventricle, regional systolic function has often deteriorated despite normal ejection fraction. OBJECTIVE: To correlate regional systolic function obtained by tissue Doppler imaging (TDI) with improvement in functional status after aortic valve replacement in patients with aortic stenosis (AS). METHODS AND RESULTS: 24 hours before aortic valve replacement, 32 patients with severe AS underwent conventional and TDI echocardiography for systolic peak velocity, peak strain and peak strain rate measurement in the short-axis posterior wall. At follow-up, a composite end point of cardiovascular death, worsening of heart failure and limited exercise capacity was recorded. Before surgery, mean (SD) aortic valve area and pressure gradient were 0.69 (0.22) cm(2) and 50 (14) mm Hg, respectively. Ejection fraction was 61 (10)% and septal thickness was 15 (3) mm. Fourteen events were recorded but no cardiac death. By using the multivariate regression analysis, systolic peak strain rate (p = 0.003) was the strongest predictor of limited recovery after aortic valve replacement. The peak strain rate cut-off point was 2/s by receiver operating characteristic analysis. CONCLUSION: Irrespective of ejection fraction and thickness, strain rate is a determinant which predicts recovery after aortic valve replacement in patients with severe AS.

Isolated right ventricular dysfunction in systemic sclerosis: latent pulmonary hypertension?

Right ventricular function is frequently abnormal in patients with systemic sclerosis, but whether this is related to pulmonary vascular complications of the disease is unclear. Standard echocardiography with tissue Doppler imaging was performed at rest and during exercise for the study of right ventricular function and pulmonary circulation in 25 consecutive systemic sclerosis patients and in 13 age-matched healthy controls. When compared with the controls, the patients had no difference in systolic right ventricular pressure gradient, but a decreased pulmonary flow acceleration time, and increased right ventricular free wall thickness and end-diastolic dimensions. At the tricuspid annulus, the E maximal velocity was decreased (8.9 +/- 4 versus 11.7 +/- 2.3 cm.s(-1)) and the isovolumic relaxation time corrected to RR interval was increased (6.5 +/- 2.9 versus 4.5 +/- 2.5%). The tissue Doppler imaging profile at the mitral annulus was similar in both groups. At exercise, 18 patients had a decreased maximum workload and cardiac output, no change in systolic right ventricular pressure gradient, but an increase in the slope of pulmonary artery pressure/flow relationships. These results suggest that patients with systemic sclerosis may present with latent pulmonary hypertension as a likely cause of right ventricular diastolic dysfunction, as revealed by stress echocardiography and tissue Doppler imaging.

Non-invasive diagnosis of coronary artery disease by quantitative stress echocardiography: optimal diagnostic models using off-line tissue Doppler in the MYDISE study.

AIMS: To develop optimal methods for the objective non-invasive diagnosis of coronary artery disease, using myocardial Doppler velocities during dobutamine stress echocardiography. METHODS AND RESULTS: We acquired tissue Doppler digital data during dobutamine stress in 289 subjects, and measured myocardial responses by off-line analysis of 11 left ventricular segments. Diagnostic criteria developed by comparing 92 normal subjects with 48 patients with coronary disease were refined in a prospective series of 149 patients referred with chest pain. Optimal diagnostic accuracy was achieved by logistic regression models, using systolic velocities at maximal stress in 7 myocardial segments, adjusting for independent correlations directly with heart rate and inversely with age and female gender (all p<0.001). Best cut-points from receiver-operator curves diagnosed left anterior descending, circumflex and right coronary disease with sensitivities and specificities of 80% and 80%, 91% and 80%, and 93% and 82%, respectively. All models performed better than velocity cut-offs alone (p<0.001). CONCLUSION: Non-invasive diagnosis of coronary artery disease by quantitative stress echocardiography is best performed using diagnostic models based on segmental velocities at peak stress and adjusting for heart rate, and gender or age.

[Percutaneous artificial heart valves: from animal experimentation to the first human implantation in a case of calcified aortic stenosis]. / Valves cardiaques artificielles percutanées: de l'expérimentation animale à la première implantation humaine dans un cas de rétrécissement aortique calcifié.

The development of artificial cardiac valves capable of being positioned by catheter has become an important subject for research, with the objective of treating valvular patients who are not operable or at very high surgical risk. We tested an artificial valve implantable by the percutaneous route, consisting of three leaflets of bovine pericardium sutured to the inside of a stainless steel stent, deployable by inflating a balloon. Following laboratory evaluation, this valve was implanted with success in animals, then for the first time in man, in a case of calcified aortic stenosis. The patient, a 57 year old male in cardiogenic shock, had associated multiple non-cardiac pathology and could not be operated on. Implantation was carried out by the trans-septal anterograde route, the only route available due to severe end stage arteritis. The artificial valve was deposited in the centre of the native aortic valve, without obstructing the coronaries nor reaching the mitral valve. The result was spectacular with instantaneous haemodynamic improvement and excellent valvular function confirmed by transoesophageal echocardiography every 15 days after implantation. Non-cardiac complications marred the progress, dominated by aggravation of pre-existing leg ischaemia, necessitating amputation for which the consequences were fatal at 4 months. This case demonstrates that implantation of a cardiac valve by the percutaneous route is possible in calcified aortic stenosis, and that it brings rapid clinical improvement. This technique could in future constitute an important alternative therapeutic approach for selected patients.

[What indicators for tissue Doppler?]. / Quels indices utiliser en Doppler tissulaire?

The analysis and quantification of regional myocardial function are necessary in numerous pathologies, of which ischaemic cardiomyopathy figures above all. Several ultrasound techniques have been developed with the objective of quantifying regional function. Among these methods, myocardial tissular Doppler is well placed, analysing the radial and longitudinal components of the myocardial fibres with different indices: movement indices (myocardial velocity and displacement) deformation indices (speed of deformation which is just the myocardial velocity gradient multiplied by the relative myocardial distance and deformation). The measurement of speeds, particularly at the level of the mitral ring, is a now well validated tool for the analysis of left ventricular filling. However, other indices (deformation in particular) are still being evaluated.

[Measurement of the mitral area with three-dimensional cardiac echography]. / Mesure de la surface mitrale par échographie cardiaque tridimensionnelle.

Two dimensional planimetry of mitral stenosis is sometimes difficult due to the complex morphology of the mitral valve. Three dimensional cardiac echography images the projected area of the mitral valve allowing precise planimetry of the orifice. Thirty patients with mitral stenosis were included in this study in order to obtain planimetry of the mitral orifice with two dimensional and three dimensional "freehand" mode transthoracic echocardiography. In 10 patients, the measurements were taken before and after percutaneous commissurotomy. The mitral area measured with three dimensional echography was 1.36+/-0.45 cm2 and 1.39+/-0.43 cm2 in two dimensional mode. The correlation between the 2 methods was good (y=1.01x - 0.08, r=0.92, p<0.001) but three dimensional echocardiography significantly underestimated the two dimensional planimetry by 0.05+/-0.27 cm2 (4+/-20%, p<0.05). The intra- and inter-observer reproducibility of the three dimensional measurements were 0.95 and 0.91 respectively. Three dimensional free-hand mode cardiac echography allows precise measurement of the mitral orifice area in patients with mitral stenosis.

[Changes in left ventricular torsion during ischemia-reperfusion]. / Altérations de la rotation systolique du ventricule gauche au cours de l'ischémie-reperfusion.

We aimed to characterise the alterations of left ventricular twist during ischaemia-reperfusion and to study their relationship to global left ventricular function. Systolic left ventricular twist was measured at the mid-papillary muscle level by colour tissue Doppler echocardiography in 7 anaesthetised open-chest dogs at baseline, 90 min-occlusion of the left anterior descending, and 180 min after reflow. Tissue Doppler was also performed in 34 patients after anterior infarct and in 20 controls. In controls, rotation occurred counterclockwise when viewed from the base. In a random subset of subjects, the assessment of ventricular twist by tissue Doppler was validated against magnetic resonance myocardial tagging. Myocardial ischaemia led to a decrease in ventricular twist in dogs and infarct patients (p < 0.01). This decrease was correlated with the extent of the asynergic area and global left ventricular function (p < 0.001). In dogs, cardiac twist was higher after reflow relative to ischaemia (p < 0.01). Thus, acute myocardial ischaemia is responsible for a decrease in left ventricular twist that is related to global ventricular function. Colour tissue Doppler echocardiography provides straightforward assessment of left ventricular twist in humans.

Recurrent cerebrovascular events associated with patent foramen ovale, atrial septal aneurysm, or both.

BACKGROUND: Patent foramen ovale and atrial septal aneurysm have been identified as potential risk factors for stroke, but information about their effect on the risk of recurrent stroke is limited. We studied the risks of recurrent cerebrovascular events associated with these cardiac abnormalities. METHODS: A total of 581 patients (age, 18 to 55 years) who had had an ischemic stroke of unknown origin within the preceding three months were consecutively enrolled at 30 neurology departments. All patients received aspirin (300 mg per day) for secondary prevention. RESULTS: After four years, the risk of recurrent stroke was 2.3 percent (95 percent confidence interval, 0.3 to 4.3 percent) among the patients with patent foramen ovale alone, 15.2 percent (95 percent confidence interval, 1.8 to 28.6 percent) among the patients with both patent foramen ovale and atrial septal aneurysm, and 4.2 percent (95 percent confidence interval, 1.8 to 6.6 percent) among the patients with neither of these cardiac abnormalities. There were no recurrences among the patients with an atrial septal aneurysm alone. The presence of both cardiac abnormalities was a significant predictor of an increased risk of recurrent stroke (hazard ratio for the comparison with the absence of these abnormalities, 4.17; 95 percent confidence interval, 1.47 to 11.84), whereas isolated patent foramen ovale, whether small or large, was not. CONCLUSIONS: Patients with both patent foramen ovale and atrial septal aneurysm who have had a stroke constitute a subgroup at substantial risk for recurrent stroke, and preventive strategies other than aspirin should be considered.

Chronic ACE inhibition enhances the endothelial control of arterial mechanics and flow-dependent vasodilatation in heart failure.

Reduced conduit arteries flow-dependent dilatation and altered compliance have been described during heart failure. However, the role of shear stress, the relation between endothelial dysfunction and mechanics, and the effect of chronic ACE inhibition on this relationship have not been investigated. The present study was designed to evaluate in heart failure patients the relationship between flow-dependent dilatation and radial artery mechanics at known shear stress levels and to assess the effect of chronic ACE inhibition. Sixteen stable congestive heart failure patients, who had never been treated with ACE inhibitors, participated in the study. Arterial pressure, cardiac output (bioimpedance), radial artery diameter (echo tracking) and flow (Doppler), total blood viscosity, and mean artery wall shear stress were assessed before and during a gradual increase in the forearm blood flow in response to gradual distal hand skin heating. Cross-sectional radial artery compliance and distensibility indexes were calculated at 34 degrees C, 40 degrees C, and 44 degrees C. The endothelium-independent vasodilatation was evaluated by use of glyceryl trinitrate. All parameters were assessed before and 24 hours after the last administration of perindopril (4 mg once daily) or placebo in a 2-month double-blind randomized study. Before treatment, there was no difference between the 2 groups for all parameters. After chronic ACE inhibition, systolic arterial pressure decreased at baseline from 126+/-11 to 118+/-10 mm Hg (P<0.05). During heating, the increase in diameter in response to shear stress was higher after ACE inhibition than after placebo (time/treatment interaction, P<0.05). Moreover, in contrast to placebo, at the same shear stress, there was a significant increase in compliance (3.23+/-0.79 x 10(-7) to 6.82+/-2.47 x 10(-7) m(2)/kPa, P<0.05) and distensibility (5.71+/-1.35 x 10(-3) to 8.87+/-1.88 x 10(-3)/kPa, P<0.05) during heating after ACE inhibition. The effect of glyceryl trinitrate did not change. The present study demonstrates that chronic administration of the ACE inhibitor perindopril increases the magnitude of the flow-dependent dilatation and restores the flow-dependent increase in compliance and distensibility of the radial artery evaluated at stable shear stress. In addition, the decrease in baseline systolic arterial pressure after ACE inhibitor suggests an associated increase in the distensibility of the proximal elastic conduit arteries.

Anticoagulant (fluindione)-aspirin combination in patients with high-risk atrial fibrillation. A randomized trial (Fluindione, Fibrillation Auriculaire, Aspirin et Contraste Spontané; FFAACS).

BACKGROUND: A combination of low-dose aspirin with anticoagulants may provide better protection against thromboembolic events compared to anticoagulants alone in high-risk patients with atrial fibrillation. OBJECTIVE: Evaluation of the preventive efficacy against nonfatal thromboembolic events and vascular deaths of the combination of the oral anticoagulant fluindione and aspirin (100 mg) in patients with high-risk atrial fibrillation. METHODS: A multicenter, placebo-controlled, double-blind, randomized trial was conducted at 49 investigating centers in France. Atrial fibrillation patients with a previous thromboembolic event or older than 65 years and with either a history of hypertension, a recent episode of heart failure or decreased left ventricular function were included in the study. Patients were treated with fluindione plus placebo (i.e. anticoagulant alone) or fluindione plus aspirin (i.e. combination therapy), with an international normalized ratio target of between 2 and 2.6. The combined primary endpoint was stroke (ischemic or hemorrhagic), myocardial infarction, systemic arterial emboli or vascular death. The secondary endpoint was the incidence of hemorrhagic complications. RESULTS: The 157 participants (average age 74 years; 52% women; 42% with paroxysmal atrial fibrillation) were followed for an average of 0.84 years. Three nonfatal thromboembolic events were observed (1 in the anticoagulation group, 2 in the combination group) and 6 patients died (3 in the anticoagulation group, 3 in the combination group), none of them from a thromboembolic complication. However, 3 deaths were secondary to severe hemorrhagic complications (1 in the anticoagulation group, 2 in the combination group). Nonfatal hemorrhagic complications occurred more often in the combination group (n = 10, 13.1%) compared to the anticoagulation group (n = 1, 1.2%) (p = 0.003). CONCLUSION: The combination of aspirin with anticoagulant is associated with increased bleeding in elderly atrial fibrillation patients. The effect on thromboembolism and the overall balance of benefit to risk could not be accurately assessed in this study due to the limited number of ischemic events.

Echocardiography predicts embolic events in infective endocarditis.

OBJECTIVES: The aim of our study was to assess the value of transesophageal echocardiography (TEE) in predicting embolic events (EEs) in a large group of patients with definite endocarditis according to the Duke criteria, including silent embolism. BACKGROUND: The value of echocardiography in predicting embolism in patients with endocarditis remains controversial. Some studies reported an increased risk of embolism in patients with large and mobile vegetations, whereas other studies failed to demonstrate such a relationship. METHODS: Multiplane transesophageal echocardiograms of 178 consecutive patients with definite infective endocarditis (IE) were analyzed. The incidence of embolism was compared with the echocardiographic characteristics (localization, size and mobility) of the vegetations. To detect silent embolism, cerebral and thoraco-abdominal scans were performed in 95% of patients. RESULTS: Among 178 patients, 66 (37%) had one or more EEs. There was no difference between patients with and without embolism in terms of age, gender and left valve involved. On univariate analysis, Staphylococcus infection, right-side valve endocarditis and vegetation length and mobility were significantly related to EEs. A significant higher incidence of embolism was present in patients with vegetation length >10 mm (60%, p < 0.001) and in patients with mobile vegetations (62%, p < 0.001). Embolism was particularly frequent among 30 patients with both severely mobile and large vegetations (> 15 mm) (83%, p < 0.001). On multivariate analysis, the only predictors of embolism were vegetation length (p = 0.03) and mobility (p = 0.01). CONCLUSIONS: Our study shows that the presence of vegetations on TEE is predictive of embolism and that the morphologic characteristics of vegetations are helpful in predicting EEs in both mitral and aortic valve IE. It also suggests that early operation may be recommended in patients with vegetations > 15 mm and high mobility, irrespective of the degree of valve destruction, heart failure and response to antibiotic therapy.