[Evaluation of left ventricular function: echocardiography, MRI or CT?]. / Evaluation de la fonction ventriculaire gauche: échocardiographie, IRM ou scanner?

The objective of this article is to clarify the advantages and limits of echocardiography, MRI, and CT for the determination of left ventricular (LV) function, emphasising the importance of evaluating global ventricular function. MRI is the reference technique, owing to its precision, reproducibility, and innocuous nature. However, echography is performed much more frequently because it is more widely available and easier to carry out. It is our reference technique in everyday practice. More recently, synchronised multi-slice tomodensitometry has provided dynamic reconstructed images of the left ventricle throughout the cardiac cycle, offering a succession of short axis views covering the entire volume of the ventricle. These acquisitions, in addition to non-invasive coronary angiography, allow the LV ejection fraction to be determined. With MRI, study of the LV function does not require any contrast medium to be injected and makes use of effective semi-automatic segmentation programs.

Aortic stenosis with severe left ventricular dysfunction and low transvalvular pressure gradients: risk stratification by low-dose dobutamine echocardiography.

OBJECTIVES: We sought to assess risk stratification by using dobutamine stress echocardiography (DSE) in patients with aortic stenosis (AS) and severe left ventricular (LV) dysfunction. BACKGROUND: Few data are available on risk stratification for valve replacement in patients with AS, LV dysfunction and low transvalvular gradients. METHODS: Low-dose DSE was performed in 45 patients (16 women and 29 men; median [quartile range] age in years: 75 [69 to 79]; left ventricular ejection fraction: 0.29 [0.23 to 0.32]; aortic valve area [cm2]: 0.7 [0.5 to 0.8]; mean transaortic gradient [mm Hg]: 26 [21 to 33]). Patients were classified into two groups: group I (n = 32, LV contractile reserve on DSE) and group II (n = 13, no contractile reserve). Valve replacement was performed in 24 and 6 patients in groups I and II, respectively. RESULTS: Perioperative mortality was 8% in group I and 50% in group II (p = 0.014). Survival at five years after the operation was 88% in group I. Compared with medical therapy, valve surgery was associated with better long-term survival in group I (hazard ratio for death [HR-D] 0.13, 95% confidence interval [CI] 0.002 to 0.49) and reduced survival in group II (HR-D 19.6, 95% CI 2.7 to 142). The effect of valve surgery on survival remained significant in both groups after adjustment for age, diabetes, respiratory disease and hypertension. Medical therapy had the same effect in both groups. CONCLUSIONS: In patients with AS, LV dysfunction and low transvalvular gradients, contractile reserve on DSE is associated with a low operative risk and good long-term prognosis after valve surgery. In contrast, operative mortality remains high in the absence of contractile reserve.

Prediction of functional recovery of viable myocardium after delayed revascularization in postinfarction patients: accuracy of dobutamine stress echocardiography and influence of long-term vessel patency.

OBJECTIVES: We sought to evaluate dobutamine stress echocardiography (DSE) for predicting recovery of viable myocardium after revascularization with cineangiography as a gold standard for left ventricular (LV) function. We studied the influence of late vessel reocclusion on regional LV function. BACKGROUND: Dobutamine stress echocardiography is a well established evaluation method for myocardial viability assessment. In previous studies the reference method for assessing LV recovery was echocardiography, long-term vessel patency has not been systematically addressed. METHODS: Sixty-eight patients with a first acute myocardial infarction (AMI) and residual stenosis of the infarct related artery (IRA) underwent DSE (mean +/- standard deviation) 21 +/- 12 days after AMI to evaluate myocardial viability. Revascularization of the IRA was performed in 54 patients by angioplasty (n = 43) or bypass grafting (n = 11). Coronary angiography and LV cineangiography were repeated at four months to assess LV function and IRA patency. RESULTS: Sensitivity and specificity of DSE for predicting myocardial recovery after revascularization were 83% and 82%. In the case of late IRA patency, specificity increased to 95%, whereas sensitivity remained unchanged. In the 16 patients with myocardial viability and late IRA patency, echocardiographic wall motion score index decreased after revascularization from 1.83 +/- 0.15 to 1.36 +/- 0.17 (p = 0.0001), and left ventricular ejection fraction (LVEF) increased from 0.52 +/- 0.06 to 0.57 +/- 0.06 (p = 0.0004), whereas in five patients, reocclusion of the IRA prevented improvement of segmental or global LV function despite initially viable myocardium. CONCLUSIONS: Dobutamine stress echocardiography is reliable to predict recovery of viable myocardium after revascularization in postinfarction patients. Late reocclusion of the IRA may prevent LV recovery and influence the accuracy of DSE.

[Stress echo and valvular heart disease]. / Echographie de stress et valvulopathies.

Stress echo has already been validated in some forms of valvular heart disease, especially in calcific aortic stenosis with low cardiac output and dynamic mitral regurgitation (MR) of valvular heart disease. Stress Doppler haemodynamics is a term used to differentiate these new indications from that of segmental wall analysis of the left atrium in ischaemic heart disease. In calcific aortic stenosis with low output, the haemodynamics with low dose dobutamine allows assessment of the real severity of the aortic stenosis and identification of the rare cases with mild stenosis: the principal indication remains the assessment of operative risk and long-term prognosis by the study of left ventricular contractile reserve. In cases of ischaemic left ventricular systolic dysfunction, the presence of mild mitral regurgitation (regurgitant surface area >20 mm2 at rest) is a poor prognostic factor. The dynamic character of mitral regurgitation is related to left ventricular remodelling which leads to deformation of the valvular apparatus (mitral tenting). Dynamic mitral regurgitation (regurgitant orifice area >13 mm2 on exercise) is a powerful prognostic factor, the role of which has recently been demonstrated in the genesis of acute pulmonary oedema. the other indications of stress haemodynamics are under validation, mainly the assessment of exercise capacity and valvular compliance in mitral stenosis or asymptomatic aortic stenosis.

[Echocardiography and mechanical complications of recent myocardial infarction]. / Echocardiographie et complications mécaniques de l'infarctus du myocarde récent.

The constantly advancing technology of echocardiography and its widespread usage in the intensive care unit has made it a routine examination in patients with acute myocardial infarction. It has become the reference method for diagnosis and monitoring of certain complications such as pericardial effusion, intra-ventricular thrombosis, ventricular aneurysm and mitral regurgitation. The echocardiographic description of these complications dates back to the 1980s during which prospective studies accurately described the principal abnormalities. These descriptions have not been much improved upon with the advent of new technology. On the other hand, the frequency of these complications assessed in an era when reperfusion by thrombolysis or primary angioplasty was much less common than today, has considerably decreased.

[Dobutamine hemodynamics for aortic stenosis with left ventricular dysfunction]. / Rôle de l'hémodynamique Doppler de stress dans la prise en charge des rétrécissements aortiques avec dysfonction ventriculaire gauche.

Patients with aortic stenosis (AS) and left ventricular (LV) systolic dysfunction have a poor short-term prognosis. In this setting, the decrease in transaortic gradients has an independent prognostic value for operative risk and long-term outcome. The 2 main issues for these patients are: (1) The real severity of AS; (2) How to stratify operative risk and evaluate long-term prognosis. Dobutamine Hemodynamics has the potential to address these issues. In case of relative AS, valve area is increased by dobutamine (final valve area > 1.2 cm2 with a mean pressure gradient <30 mmHg); on the basis of published data, medical treatment is justified in this case. Left ventricular contractile reserve is defined an increase in stroke volume, by 20% or more, under dobutamine. Operative risk is between 5 and 11% in case of LV contractile reserve and long-term outcome is improved by surgery in this case. In contrast, operative risk varies from 30 to 60% in case of exhausted reserve; this risk is also determined by other factors such as the presence of coronary artery disease and associated comorbidities. All these parameters are factored into risk-benefit analysis in order to determine the best therapeutic approach for each patient.

Comparison of arbutamine and exercise echocardiography in diagnosing myocardial ischemia.

Arbutamine is a new catecholamine designed for use as a pharmacologic stress agent. This study compared the sensitivity of arbutamine with symptom-limited exercise to induce echocardiographic signs of ischemia. Arbutamine was administered by a computerized closed-loop delivery system that controls the infusion rate of arbutamine toward a predefined rate of heart rate increase and maximum heart rate limit. Beta blockers were stopped > or = 48 hours before both tests. Stress was stopped for intolerable symptoms, or clinical, electrocardiographic or echocardiographic signs of ischemia (new or worsening wall motion abnormality), target heart rate (> or = 85% age predicted maximum heart rate), or plateau of heart rate response. Thirty-seven patients were entered into the study (35 arbutamine and exercise, 1 arbutamine only, 1 exercise only), of which 30 had angiographic evidence of coronary artery disease (> or = 50% lumen diameter narrowing). Rate-pressure product increased significantly in response to both stress modalities (p < 0.001) and was significantly greater with exercise (11,308 +/- 2,443) than with arbutamine (9,486 +/- 2,479, p < 0.001). The time to maximum heart rate was longer during arbutamine stress echocardiography than during exercise testing (17.3 +/- 9.4 versus 9.3 +/- 4.2 minutes, respectively, p < 0.001). There were more patients with interpretable echo data for arbutamine (82%) than for exercise (67%). Sensitivity for recognition of myocardial ischemia was 94% (95% confidence interval 70% to 100%) and 88% (95% confidence interval 62% to 98%), respectively. The most frequent adverse events during arbutamine (n = 36) were dyspnea (5.6%) and tremor (5.6%). Two arbutamine stress tests were discontinued due to arrhythmias: 1 patient had premature atrial and ventricular beats, and the other had premature atrial contractions and atrial fibrillation. Arrhythmias were well tolerated and resolved without sequelae. In conclusion, the sensitivity of arbutamine to induce echocardiographic signs of ischemia was similar to that of exercise despite a lower rate-pressure product. Arbutamine was well tolerated and provides a reliable alternative to exercise echocardiography.

Effect of delayed percutaneous transluminal coronary angioplasty of occluded coronary arteries after acute myocardial infarction.

Whether angioplasty of occluded vessels after myocardial infarction may have beneficial effects on left ventricular function remains unknown. Patients with a first myocardial infarction and thrombolytic therapy who had an occluded infarct-related vessel at delayed coronary angiography were referred systematically for an elective coronary angioplasty performed between 3 and 4 weeks after the myocardial infarction. All patients underwent stress-redistribution-reinjection thallium-201 single-photon emission computed tomography for myocardial viability assessment. Prior angioplasty, a quantitative evaluation of global and regional left ventricular function, was performed. The study group consisted of 38 patients (aged 57 +/- 10 years); 18 had anterior wall infarctions and 20 inferior wall infarctions, but before angioplasty 3 had a patent artery and were excluded. Angioplasty was successful in 30 patients. At follow-up 13 patients (43%) had an occluded coronary artery. In contrast with patients with an occluded coronary artery at follow-up, those with a patent coronary artery had no left ventricular enlargement and had an improvement in both left ventricular ejection fraction (from 48 +/- 9% to 52 +/- 9.8%, p = 0.002) and regional wall motion index (delta = +0.95 SD, p <0.01). In patients with a patent vessel at follow-up, there was a positive correlation between the number of myocardial viable segments and improvement of the infarct zone wall motion (r = 0.52; p = 0.035), and the number of necrotic segments at baseline was positively correlated to the 4-month changes in end-diastolic volume indexes (r = 0.6; p = 0.04). Thus, elective revascularization of occluded coronary arteries with viable myocardium after myocardial infarction improves left ventricular function and lessens remodeling if the artery remains patent during follow-up.

Usefulness of redistribution images in viability detection after acute myocardial infarction.

We undertook this study to evaluate the importance of redistribution images in thallium 201 single-photon emission computed tomography (Tl-201 SPECT) assessment of myocardial viability after acute myocardial infarction. Stress-redistribution-reinjection Tl-201 SPECT was performed in 55 consecutive patients with recent (within 1 month) acute myocardial infarction. The myocardium was divided into 16 segments and activity assessed visually with a score from 0 to 3 on stress-redistribution and stress-reinjection images. A defect was considered moderate if the stress score was 2 and severe if the stress score was 0 or 1. All moderate defects were considered viable, regardless of score on redistribution or reinjection images. Severe defects were considered viable if they were reversible (improvement of 1 score) on redistribution or reinjection images. Stress-redistribution and stress-reinjection images were visually analyzed and compared in terms of viability classification. On visual analysis, 461 segments (52%) were abnormal. One hundred eleven stress defects were moderate; of these, 28 were reversible on reinjection images only and 15 on redistribution images only. However, all of these segments were viable, regardless of the analysis chosen. Of 350 severe stress defects, 48 were reversible on reinjection and irreversible on redistribution images, and 4 were reversible on redistribution and irreversible on reinjection images. Therefore, in viability assessment, 48 segments were misclassified with stress-redistribution analysis, whereas only 4 segments were misclassified using stress-reinjection analysis. Although the usefulness of Tl-201 reinjection imaging is confirmed, redistribution images seem to be of little interest in post-myocardial infarction viability assessment.

Stratification of single-vessel coronary stenosis by ischemic threshold at the onset of wall motion abnormality during continuous monitoring of left ventricular function by semisupine exercise echocardiography.

We studied the relation between the ischemic threshold at the onset of wall motion abnormality on exercise echocardiography (EE) and the severity of coronary stenosis in patients with 1-vessel coronary artery disease (CAD). We screened 216 consecutive patients who underwent coronary angiography and EE for suspected CAD. Ninety-five (74 men; age, 56 +/- 12 years) satisfied the study criteria, that is, the presence of 1-vessel disease or no evidence of CAD on angiography and a normal baseline echocardiogram. Eighty-seven patients had 1-vessel CAD on angiography, and exercise-induced wall motion abnormality occurred in 73 (77%). Optimal cutoff values of percent diameter stenosis and minimal lumen diameter for predicting a positive EE were 61% (sensitivity and specificity of 76%) and 1.12 mm (sensitivity and specificity of 74%). Among patients with positive EE, heart rate-blood pressure product at ischemic threshold was correlated with quantitative coronary stenosis (r = -0.72, P <.001). The ischemic threshold from continuous monitoring of left ventricular function during semisupine EE is correlated with the severity of coronary stenosis among patients with 1-vessel disease and a normal resting echocardiogram.

Comparison of regional myocardial velocities assessed by quantitative 2-dimensional and M-mode color Doppler tissue imaging: influence of the signal-to-noise ratio of color Doppler myocardial images on velocity estimators of the Doppler tissue imaging system.

M-mode color Doppler imaging of the myocardium affords a greater sampling rate and signal-to-noise (S/N) ratio than 2-dimensional (2D) imaging. In this study, we compared myocardial velocities assessed by 2D and M-mode Doppler tissue imaging (DTI) at the same site and evaluated the influence of the S/N ratio on velocity estimates of the currently used DTI systems. In patients with and without impaired regional left ventricular function, myocardial velocities assessed by 2D DTI were lower than those obtained with M-mode DTI. The difference between regional velocities derived from both imaging techniques was positively correlated with the extent of the "black zone," which could be considered as indirectly reflecting the S/N ratio for each frame. Thus in the clinical setting and on currently used echocardiographs, 2D DTI may provide underestimated regional myocardial velocities when compared with M-mode, mainly because of the influence of the lower sampling rate and S/N ratio on velocity estimators of the imaging system.

[Can stress echocardiography by quantified?]. / Peut-on quantifier l'échocardiographie de stress?

Stress echocardiography has been validated for the evaluation of myocardial ischaemia and viability despite a semi-quantitative interpretation based on visual analysis of segmental myocardial thickening. The technique remains, therefore, partially subjective, which probably affects its diagnostic value and reproducibility, especially during the learning period of a non-expert operator. A first step towards better reproducibility was made possible by Second Harmonic imaging and standardised interpretation according to the recommendations of the American Society of Echocardiography. The quantification is based on the analysis of numerical data obtained by Doppler tissue imaging or color kinesis. Doppler Tissular Imaging in the pulsed mode with analysis of transparietal velocity gradients or regional deformation is currently under evaluation. However, the use of threshold values for myocardial velocities has been of little diagnostic value and the use of algorithms adjusted for age, heart rate and gender are necessary. Another approach is that of colour coding of endocardial displacement (Color Kinesis) with automatic contour detection. This relatively easy technique requires a shorter post-processing and the initial results are encouraging.

[Calcified aortic stenosis with left ventricular dysfunction and low transvalvular gradients. Must one reject surgery in certain cases?]. / Rétrécissement aortique calcifié avec dysfonction ventriculaire gauche et faibles gradients transvalvulaires. Doit-on récuser la chirurgie dans certains cas?

The natural history of severe aortic stenosis (aortic valve area < 1 cm2 or < 0.6 cm2/m2) with left ventricular systolic dysfunction and low transvalvular gradients (mean gradient < 40 mmHg) is mediocre in the short term and the operative risk is high. Dobutamine echocardiography provides a reliable evaluation of the aortic obstacle by diagnosing the rare cases of relative aortic stenosis in which the valve surface area has been underestimated because of a low cardiac output (aortic surface area > 1.2 cm2 with a mean gradient < 30 mmHg with dobutamine): in this case, the limited available data suggests that medical therapy with strict follow-up of its efficacy is the best management. The other use of dobutamine echocardiography is to assess left ventricular contractile reserve, defined as a increase > or = 20% in stroke volume under dobutamine. Cases with a contractile reserve have an operative risk of 5 to 10% and the medium-term benefits of valve replacement have been demonstrated. In the absence of contractile reserve, the operative risk is much grater, 30 to 60%, and also depends on other parameters such as the mean basal transaortic pressure gradient (risk five times greater in cases with a mean gradient < 20 mmHg), the need for coronary bypass surgery and associated co-morbid conditions. The surgical contraindications are in fact relatively few and concern patients with several risk factors: absence of contractile reserve itself is not a definitive surgical contraindication.

[Chronic ischemic left ventricular dysfunction: myocardial hibernation?]. / Dysfonction ventriculaire gauche chronique d'origine ischémique: hibernation myocardique?

Hibernating myocardium is a term which covers chronic ischaemic left ventricular dysfunction which is potentially reversible after revascularisation. Hibernating myocardium is classically associated with chronic hypoperfusion responsible for hypocontraction and cellular degeneration. This "classical" conception has been questioned as some workers emphasise that the reduction in coronary reserve responsible for repeated episodes of ischaemia and stunning could be the main causes of myocardial dysfunction. Position emission tomography (PET), and, most of all, myocardial scintigraphy and dobutamine echocardiography are the most commonly used techniques for detecting hibernating myocardium. Their sensitivity is good but the specificity and positive predictive value of dobutamine echocardiography seems to be better than the isotopic techniques. Structural abnormalities of hibernating myocardium and the delay, which is often long, between revascularisation and improvement, may explain some of the discordances between these techniques. Irrespective of the term used, hibernation or chronic ischaemic left ventricular dysfunction with myocardial viability, the reported data is in favour of coronary revascularisation with improved long-term quality of life and reduced mortality in patients with positive viability tests.

[The best of echocardiography in 1999]. / L'essentiel de 1999 en échocardiographie.

As many techniques of medical investigation, echocardiography regularly benefits from technical innovations which, with application, prove to be extremely useful and, for some of them, even widen the field of investigation. The end of this decade has seen the introduction of major improvements. In daily practice, second harmonic imaging has been the most important technical advance with such improved quality of imaging that this mode has rapidly become the routine for transthoracic investigations in adults. All modern echocardiographs are, or can be, equipped at modest cost. Stress echocardiography, the diagnostic reliability of which is closely related to the quality of the imaging, has greatly benefited from this technique, to the point of obtaining equivalent results as nuclear medicine in the detection of myocardial ischaemia and cellular viability. The results are now sufficiently convincing for the technique to have a real prognostic value in myocardial ischaemia. Doppler tissue imaging is also a major advance but the clinical value is still under evaluation: the pulsed Doppler mode is quantifiable during the investigation, contrary to the calculation of transparietal velocity gradients which requires computerisation techniques not provided by all manufacturers. The regain in interest in contrast echocardiography is due to the development of agents which, injected intravenously, cross the pulmonary capillary barrier and opacify the left heart chambers. The reinforcement of the Doppler signal and improved detection of the endocardial echoes have justified the authorization of their commercialisation, but the essential point is their use in the investigation of myocardial perfusion which is under evaluation. Three-dimensional reconstruction has made great strides but its diffusion is still limited by the limited availability of the required powerful computers.

[Left coronaro-ventricular fistula after septal myectomy]. / Fistule coronaro-ventriculaire gauche après myectomie septale.

The authors report the case of a 17 year old patient operated for valvular aortic stenosis associated with severe hypertrophy of the interventricular septum. The operation consisted of aortic valve replacement and septal myectomy. Color-flow imaging in the postoperative period showed a coronary artery--left ventricular fistula in the region of the septal myectomy. In view of the small size of the fistula on echocardiographic examination and the absence of a codified strategy of management of acquired coronary left ventricular fistula after surgery, a simple Doppler echocardiographic follow-up was proposed in this case.

[Study of myocardial viability after recent infarction by echocardiography under dobutamine. Evidence of stunned myocardium]. / Etude de la viabilité myocardique après infarctus récent par l'échocardiographie sous dobutamine. Mise en évidence du myocarde sidéré.

After myocardial infarction treated by thrombolysis, secondary improvement of contractility may be observed due to the presence of viable but stunned myocardium in a zone of ischaemia. Echocardiography with lose dose Dobutamine has been proposed as a diagnostic test of myocardial viability. The inotropic effect of the pharmacological agent improves or induces myocardial thickening in zones of ischaemia. A positive response is observed in about one out of two cases. The sensitivity ranges from 79 to 86% and the specificity from 68 to 90% in the reported series. This mode of stress echocardiography for the study of post-infarction myocardial viability is under clinical evaluation: its advantages and limitations should be compared with those of other non-invasive methods, especially thallium myocardial scintigraphy.

[Localization of mitral valve prolapse zones with multiplane transesophageal echocardiography]. / Localisation des zones de prolapsus valvulaire mitral en échographie transoesophagienne multiplan.

CONTEXT: There are few literature data on the localization and extent of mitral valve prolapse zones with transesophageal echocardiography (TEE). AIM OF THE STUDY: To assess a standardized imaging technique for the localization and extent determination of prolapse zones, based on 3 easily reproducible views with multiplane TEE. METHODS: Seventy patients with severe mitral regurgitation due to valve prolapse requiring a multiplane TEE prior to surgery (valve repair or replacement) have been retrospectively assessed. Data of TEE on the localization and extent of prolapse zones have been confronted to per-operative anatomical observations (gold standard). RESULTS: The sensitivity of TEE for the identification of isolated P2 prolapse, prolapse with commisural extension, isolated rupture of the posterior commisure and bi-valvular prolapses were respectively at 96%, 88%, 86% and 80%. The corresponding specificities were from 98% to 100%. CONCLUSIONS: The use of a standardized technique with the use of 3 easily reproducible incidences with multiplane TEE allows a precise definition of the localization and extent of mitral valve prolapse zones, in order to potentially indicate valve repair.

[Functional study, in man, of congestive gastropathy in cirrhosis by measurement of potential difference]. / Etude fonctionnelle, chez l'homme, de la gastropathie congestive au cours de la cirrhose par la mesure de la différence de potentiel.

The morphologic features of the gastric mucosa in patients with cirrhosis have been well investigated. The aim of this study was to evaluate its functional disruption by measuring the gastric potential difference. Forty patients were investigated, 12 control subjects and 28 consecutive cirrhotic patients with endoscopically proved congestive gastropathy. Potential difference was measured the morning, on an empty stomach, at least 3 days after endoscopy; the method used a double channel gastric perfused probe placed under fluoroscopy 10 cm above the cardia, and a subcutaneous reference, both connected to a millivoltimeter via gelose agar-KCl bridges. Potential difference was recorded in each case 20 min before (baseline) and after local instillation of lysine acetylsalicylate (500 mg) as a provocative test. Cirrhotic patients had significantly lower basal potential difference than controls (-28.3 +/- 1.5 mV vs -33.8 +/- 1.3mV, p = 0.007). Potential difference was significantly lower in patients with severe gastropathy than in patients with mild gastropathy (-20.5 +/- 2.1 and -28.9 +/- 1.6 mV, respectively, p less than 0.01). After stimulation with acetylsalicylate, the area under curve and the irritability index were greater in patients with gastropathy (81.4 +/- 12.8 vs 41.2 +/- 8.6 mV.min, p = 0.032 and 0.935 +/- 0.19 vs 0.290 +/- 0.07 mV.mV.min, p = 0.022, respectively). These differences were explained by a higher drop in potential difference (delta DPmax/baseline; 28.1 +/- 3 vs 16.1 +/- 3 p. 100, p = 0.006) whereas basal return time remained unchanged (16.2 +/- 2.1 vs 13.7 +/- 2.2 min).(ABSTRACT TRUNCATED AT 250 WORDS)

[Practical value of the detection of silent myocardial ischemia in patients with coronary disease using Holters]. / Intérêt pratique de la détection de l'ischémie myocardique silencieuse chez le coronarien par les Holters.

The prognosis of painless myocardial ischemia is similar to that of symptomatic ischemia. The Holter technique (and solid memory Holter in particular) is a simple method of detection which, taken together with exercise testing, enables the identification among coronary disease patients of a high risk group in whom effort ischemia is accompanied by episodes of ischemia under everyday conditions and in whom additional investigations (exercise thallium scan then coronary arteriography) and appropriate treatment, including transluminal angioplasty and aorto-coronary bypass if necessary, may be required. The role of drug treatment in silent ischemia has not yet been clearly defined. While electrical ischemia regresses significantly with the majority of standard drug regimens, and beta-blockers in particular, none has yet been confirmed as having a preventive effect against serious events following on from silent myocardial ischemia.