Compliance and antihypertensive efficacy of amlodipine compared with nifedipine slow-release.

Poor compliance is a principal cause of treatment failure in hypertensive patients. Once-daily dosing improves compliance, but 24-h antihypertensive activity should be provided. The compliance, efficacy, and safety of amlodipine and nifedipine slow-release (SR) were compared in patients with mild-to-moderate essential hypertension recruited among 24 centers in France. After a 2-week washout period, 103 patients were randomized to 12 weeks of 5 to 10 amlodipine mg once daily (n = 55) or 20 mg nifedipine SR twice daily (n = 48). Compliance was calculated by electronic drug monitoring. Efficacy was measured by ambulatory and casual BP recordings. Patients receiving amlodipine demonstrated better compliance than patients receiving nifedipine SR with respect to compliance index (the total number of doses taken divided by the total number of doses prescribed, expressed as a percentage; 98.3% v 87%; P < .0001), days on which the correct number of doses were taken (92.5% v 74.8%; P < .0001), and prescribed doses taken on schedule (88.7% v 71.6%; P < .0001). Absolute and relative therapeutic coverage were higher in patients receiving amlodipine than nifedipine SR (P < .0001). Mean SBP and DBP decreased equally in both groups, although amlodipine offered better BP control compared with nifedipine SR at specific times of day. Fewer patients had high nocturnal SBP with amlodipine (39.3%) than nifedipine SR (71.4%; P = .042). Adverse events and treatment withdrawals occurred less frequently in amlodipine-treated patients than in nifedipine SR-treated patients. Amlodipine (5 to 10 mg) once daily provides improved compliance, better 24-h BP control, and fewer adverse events than 20 mg nifedipine SR twice daily in patients with mild-to-moderate hypertension.

[Heart rate and diabetes mellitus]. / Fréquence cardiaque et diabète sucré.

Diabetic neuropathy, particularly autonomic disorders, is early and frequent. When it affects the heart, it is also called cardiac autonomic neuropathy (CAN) and its clinical manifestations, especially increased heart rate, and subclinical manifestations are reported here, together with the techniques used to study this disease: Ewing's test, "Finapres", Holter ECG. Tachycardia, occurs early, is almost constant during diabetes and has a prognostic value.

[Heart rate and lipids]. / Fréquence cardiaque et lipides.

Heart rate (HR) appears to be an independent marker of cardiovascular risk, based on certain epidemiological data. Several studies have tried to establish a predictive cutt-off value. Many studies have observed the existence of a positive and independent correlation between HR and triglyycerides, VLDL, and a negative correlation between HR and HDL cholesterol. The recommended techniques for HR measurement, pathophysiological hypotheses, and clinical implications are discussed.

[Post-embolic chronic pulmonary heart disease: a case report]. / Coeur pulmonaire chronique post-embolique: à propos d'une observation.

Echocardiography and pulmonary scintigraphy demonstrated post-embolic chronic cor pulmonale in a six-year-old woman presenting with dyspnoea. The patient's symptoms deteriorated during subsequent thromboembolic episodes, despite treatment consisting of oral anticoagulants and diuretics. After discussing the pathophysiology and diagnostic methods, the authors emphasize the limits of medical treatment of post-embolic chronic cor pulmonale and the value of two surgical treatments: thromboendarterectomy and lung transplantation. They also recall the precise selection criteria for lung transplantation.

[Effect of diltiazem on lipid profiles and heart rate in hypertensive patients]. / Etude de l'effet du diltiazem sur le profil lipidique et la fréquence cardiaque des patients hypertendus.

Diltiazem is an antihypertensive belonging to the class of heart rate-slowing calcium channel blockers; its antihypertensive efficacy has been demonstrated for a long time. Controlled trials have also demonstrated that it does not interfere with lipid parameters. This open multicentre trial was designed to verify the absence of any action of diltiazem on lipid parameters as well as its effect on the heart rate of hypertensive patients. The patients included had to take one capsule of diltiazem 300 mg sustained release formulation, developed by Laboratoires Synthélabo, in the morning for 6 months. A lipid assessment and an electrocardiogram were performed before and at the end of the trial. One hundred and forty-six patients were included: 81 underwent a complete lipid assessment (7 parameters) before and after treatment and 69 underwent an electrocardiogram at rest to the same study times. Total cholesterol (p = 0.0007), LDL cholesterol (p = 0.005) and apoprotein A1 (p = 0.0002) were significantly decreased. Blood pressure decreased progressively throughout the study and was "controlled" (supine diastolic blood pressure < or = 90 mmHg) after six months of treatment in 77% of patients. Heart rate decreased significantly at the end of the study; no pathological variation of PR, QRS and Qt intervals was observed. The effect on heart rate, also studied in patient subgroups defined by their baseline values, was more marked when the baseline heart rate was increased. The investigators considered the safety to be good at each visit, in 80% of cases. Sixteen patients dropped out of the trial because of adverse effects or intercurrent disease. The adverse effects most frequently reported were oedema of the lower limbs (7.5%), headache (4.8%) and hot flushes (2.7%). No harmful effect of diltiazem on lipid parameters was observed during this open trial; some lipid parameters even decreased at the end of treatment. Clinically, diltiazem lowered blood pressure and decreased heart rate. The reduction of heart rate was more marked in the case of high baseline heart rate. Safety was satisfactory.

[Multifactor prevention of endocarditis and cardiac pacemakers. A prospective study apropos of 207 patients]. / Prévention polyfactorielle des endocardites et stimulateurs cardiaques. Une étude prospective à propos de 207 patients.

Infections after cardiac pacemaker implantation are rare (0.13 to 12.6%) but potentially severe complications. Staphylococcus is the genus most frequently isolated (72 to 100% of cases). The use of systematic prophylactic antibiotics remains controversial. From November 1991 to October 1993, 207 consecutive patients were submitted to a series of measures designed to reduce the risk of infection: a) intravenous bolus injection of Cefamindole, 15 minutes before implantation, b) cutaneous disinfection with iodinated polyvindone, c) injection of an ampoule of rifampin before closure of the pacemaker in the pouch, d) absence of drainage system. Patients were predominantly female (60.9%), with a mean age of 77 +/- 10 years, frequently suffering from heart disease (53.8%). The indication for implantation was atrioventricular block (39.7%), carotid sinus syndrome (27.5%), atrial arrhythmia (27.5%), resection of the node-His tract (5.3%). This procedure corresponded to the first implantation in 88.4% or replacement of a previous pacemaker in 11.6% of cases and the pacing mode was single-chamber (38.4% or replacement of a previous pacemaker in 11.6% of cases and the pacing mode was single-chamber (38.7%), or double chamber (61.3%). The mean duration of the procedure was 51.5 min +/- 30 min. The mean follow-up was 12.7 +/- 5 months. The overall mortality was 14% (11 cases of cardiac failure, 6 sudden deaths, 4 cerebrovascular accidents, 4 cases of pneumonia, 4 neoplasms). Only one infectious problem (endocarditis, i.e. 0.48%) was observed.

Prospective evaluation of high-dose or low-dose isoproterenol upright tilt protocol for unexplained syncope in young adults.

The sensitivity of the passive head-up tilt test (HUT) in the evaluation of unexplained short-lasting syncope in young adults remains insufficient. The infusion of isoproterenol was proposed to improve the benefit. To evaluate the sensitivity-specificity relationship during isoproterenol dosing, we studied 76 young adults (aged 20.9 +/- 1.7 years) (group S) with recurrent (mean 3.8 +/- 1.6) losses of consciousness that remained unexplained after clinical and noninvasive assessment and 35 young healthy volunteers (aged 22.6 +/- 2.7 years) (group V). Subjects underwent either passive HUT (45 min, 60 degrees without drug dosing for 48 subjects in group S (S1) and 17 in group V (V1), or HUT with isoproterenol infusion at progressive doses (2 then 5 micrograms/min) after 30 minutes of passive tilting for 28 patients in group S (S2) and 18 in group V (V2). During passive HUT, the test was positive (asystole, bradycardia, or fall in systolic blood pressure) in 2 of 17 (11.8%) patients in group V1 and in 7 of 48 (14.6%) in group S1 before 30 minutes, and in 3 of 17 (17.6%) in group V1 compared with 10 of 48 (20.8%) in group S1 at the end of the 45-minute infusion, with no difference in delay before the appearance of a positive result. During HUT with isoproterenol dosing, the test was positive in 2 of 18 (11.1%) patients in group V2 and in 18 of 28 (64.2%) in group S2 before 45 minutes (2 micrograms/min; p < 0.01) in 7 of 18 (38.8%) in group V2 compared with 24 of 28 (85.7%) in group S2 before 60 min (5 micrograms/min; p < 0.01). In both cases the mean delay in evoking a positive response was significantly shorter. No asystolic response was observed in the volunteers regardless of the protocol used. The most characteristic response to isoproterenol injection was the appearance of a junctional escape rate with a fall in systolic blood pressure (61.5% of subjects in group S2). The infusion of isoproterenol considerably improves the sensitivity of the HUT with satisfactory specificity if low doses are used (< 3 micrograms/min). These results support the use of HUT with isoproterenol in the evaluation of unexplained syncope in young adults.