Prognostic value of thallium-201 single-photon emission computed tomographic myocardial perfusion imaging according to extent of myocardial defect. Study in 1,926 patients with follow-up at 33 months.

OBJECTIVES: This study was designed to assess the prognostic value of thallium-201 single-photon emission computed tomographic (thallium SPECT) perfusion imaging in patients evaluated for stable angina pectoris and to examine the relation, if any, between the presence and extent of myocardial defect and future fatal or nonfatal cardiovascular events (revascularization, secondary myocardial infarction). BACKGROUND: Compared with planar scintigraphy, thallium SPECT enables better evaluation of the extent of myocardial perfusion defect. However, its prognostic value has not yet been studied in a large population of patients. METHODS: Between 1987 and 1989 we studied 3,193 patients. After exclusion of patients with unstable angina, myocardial infarction during the previous month or earlier revascularization, 1,926 patients were followed up for 33 +/- 10 (mean +/- SD) months after stress thallium SPECT imaging (performed after exercise in 1,121 patients or during dipyridamole infusion in 805 patients). Thallium SPECT imaging of the left ventricle was divided into six segments. RESULTS: After normal thallium SPECT imaging (715 patients), the annual total and cardiovascular mortality rates were, respectively, 0.42%/year and 0.10%/year and were significantly higher after abnormal thallium SPECT imaging (respectively, 2.1%, relative risk 5, p = 0.012; 1.5%, relative risk 15, p < 0.0001 [log-rank test]). There was a significant relation between the number of abnormal segments and cardiovascular mortality during follow-up (p < 0.02) or the occurrence of nonfatal events (p < 0.001). The extent of defect on the initial scan provided the best SPECT variable for long-term prognosis. Thallium SPECT imaging provided additive prognostic information compared with other clinical variables (gender, previous myocardial infarction) and exercise electrocardiogram. CONCLUSIONS: In patients with stable angina, normal thallium SPECT imaging indicates a low risk patient, and the extent of myocardial defect is an important prognostic predictive factor.

[Blood pressure variability during rest and left ventricular hypertrophy in the hypertensive patients. A spectrum analytic approach]. / Variabilité de la pression artérielle au repos et hypertrophie ventriculaire gauche chez l'hypertendu. Approche par analyse spectrale.

OBJECTIVE: To study the relationship between spectral analysis measurement of blood pressure (BP) and heart rate (HR) at rest, in untreated essential hypertension, and their relationship with the development of left ventricular hypertrophy (LVH). DESIGN AND METHODS: 41 untreated hypertensives (25M/16W, age 50 +/- 12, range 23-73) were measured at rest (WHO criteria DBP > 90 mmHg) by digital continuous photoplethysmography (Finapres 2300 (F), 6 mn of measurement in the dorsal decubitus position and standing up). Measurement of LVH (Devereux criteria, left ventricular mass index LVMI, g/m2) to analyse two groups (LVMI+: LVMI > 107 if women and 120 if men; n = 19; LVMI = 137 +/- 25), and (LVMI-; n = 22; LVMI = 92 +/- 17). The overall variability is standard deviation (SD), spectral analysis variability (SA) is FFT of 256 points over 3 periods low (LF: 0.004-0.07Hz), medium (MF: 0.07-0.13Hz), high (HF: 0.13-0.5Hz). Comparisons by Wilcoxon test and Anova (age, sex) (* p < 0.05, ** p < 0.01). RESULTS: By WHO criteria, the SBP was significantly lower in the LVMI-group (153 +/- 10 vs 165 +/- 18**), the DBP was not significantly different (94 +/- 6 vs 96 +/- 10). By continuous measure (F) at rest there was no significant difference for SBP or DBP. On standing up the SBP was significantly lower in the LVMI-group (148 +/- 20 vs 162 +/- 22**). The SD of the DBP at rest was more elevated in the LVMI-group (3.34 vs 3.06*), but not significantly different standing up. There was no significant difference in SBP at rest (6.7 vs 6.32) or standing (9.13 vs 11.5). The Spectral analysis of the MF was significantly elevated in the LVMI-group at rest for SBP (3.56 vs 3.01*), DBP (1.99 vs 1.19*), and HR (1.79 vs 1.77*). This was not significantly different in the LF and HF for SBP, DBP, HR. CONCLUSION: These results are different from those obtained by invasive ambulatory measures. The spontaneous variability in BP and HR at rest is increased when there is no cardiac effect (LVMI-). SA gives additional information in showing that the increase in variability is due to an increase in the Mayer waves, suggesting the existence of an elevation in adrenergic tone in hypertensive patients not having LVH.

[Changes in the morphology of the Doppler wave of the pulmonary venous blood flow in hypertensive heart diseases]. / Variations de la morphologie du Doppler du flux veineux pulmonaire dans la cardiopathie hypertensive.

Analysis of pulmonary venous flow can contribute to understanding of ventricular diastole; 40 essential hypertensive subjects (HT) who had never been treated and 30 healthy normotensive subjects (NT) were studied by Doppler-echocardiography. All the subjects had normal systolic function on echocardiography. The analysis focussed on the velocity of transmitral flow as measured by pulsed Doppler, measuring E and A waves, and also on flow in the right superior pulmonary vein: S and D waves measured in the apical position. The D wave appeared to correlate with age (r = 0.62, p < 0.001), with systolic blood pressure (SBP) (r = -0.44, p < 0.05) a correlation which remained after adjustment for age, and for measures of diastolic function across the mitral valve: A wave, and to E wave in a less closely related fashion. The D wave was of a lower velocity with mitral Doppler type A than with normal mitral Doppler (46 +/- 9 vs 36 +/- 8 cm/s; p < 0.005). The S wave was weakly related to morphological measurements of LV such as end-diastolic diameter of LV(r = 0.3; p < 0.01). The Doppler of pulmonary venous flow may help in describing impairment in LV filling by giving complementary data on Doppler mitral flow. A type 1 mitral Doppler corresponds to a low amplitude D wave with the presence of elevation of LVEDP which limits LV filling. In difficult situations when E and A velocities are similar (normal or pseudonormal form) a weak velocity of D wave is in favour of type 1.

[Delayed potentials and left ventricular hypertrophy]. / Potentials tardifs et hypertrophie ventriculaire gauche.

Delayed potentials (DP) (ECGHA) are markers of the occurrence of ventricular rhythm disturbances, and have a prognostic value after myocardial infarction. In hypertensive heart disease, the prevalence of DP is variable according to the literature (1-40%) and their prognostic significance is not known. We examine the frequency of DP in hypertension (HT) and the relationship between DP and left ventricular hypertrophy (LVH) as defined by echocardiographic estimation of the LV mass index (LVMI). We investigated 50 consecutive patients with essential HT who were being assessed as regards cause and effects of HT. Exclusion criteria were coronary artery disease, bundle branch block and poor echocardiographic trace. ECGHA was registered by means of ART device. The presence of DP as defined according to the criteria of Kacet. LV mass was determine according to the method of Penn and LVH defined according to the criteria of Devereux. Besides LVMI, were examined age, sex, duration of HT, micro-albuminuria, LVH on ECG (Sokolow index and strain-ECG). There were no correlations between the different variables studied and the presence of DP. The results relating to LVMI are shown in Table. There were no correlation between DP and LVH on echography. Other explanations, electrophysiologic, ischemic and histological may explain the greater incidence of BP observed in hypertensive heart disease. [table: see text] The prevalence of DP was not significantly different as regard the presence or absence of LVH (35% vs 25%; p = 0.53). In the 10 patients with the highest LVMI, the DP were enregistered 3 times.

[Baroreflex regulation and blood pressure variability during rest in the hypertensive patient]. / Régulation baroréflexe et variabilité tensionnelle au repos chez l'hypertendu.

The object of this study was to compare the variability of blood pressure measured non-invasively with the Finapres under resting conditions in hypertensive patients with non-hypertensive subjects matched for age, and to evaluate the relationship between resting blood pressure, i.e. without any stimulation, and the sensitivity of the baroreflex evaluated by crossed spectral analysis (SA). Thirty-four hypertensives (WHO criteria) untreated for three weeks, with a mean age of 50 +/- 7 years, were compared with 60 control subjects with a mean age of 50 +/- 9 years. The blood pressure and heart rate were measured continuously in the dorsal decubitus and standing positions. The direct and crossed SA was undertaken by a specific programme using the fast Fourier method. The average blood pressure of controls differed significantly from that of the hypertensive population (118 +/- 15/65 +/- 10 mmHg vs 157 +/- 20/86 +/- 11 mmHg). The mean heart rate of the hypertensives was faster: 76 +/- 11 vs 67 +/- 10 beats/min (p < 0.001). Under basal conditions, there was greater absolute variability in the hypertensive subjects but the relative variability and heart rate were the same as those of the controls. Direct SA provided additional data by showing that this variability was due to LF oscillations. Crossed SA showed a change in the sensitivity of the slope of regulation of the baroreflex in hypertensives, 7.35 vs 8.68 ms/mmHg (p < 0.05). These results show that, under basal conditions, it is possible to demonstrate an increase in the absolute variability in blood pressure in hypertensive patients.(ABSTRACT TRUNCATED AT 250 WORDS)

[Relationships between ambulatory blood pressure and carotid artery diseases]. / Etude des rapports entre la pression artérielle mesurée en ambulatoire et les lésions vasculaires carotidiennes.

UNLABELLED: We studied in a retrospective study 138 consecutive hypertensive patients, the relationship between atherosclerosis lesions in carotid-artery and the ambulatory blood pressure. Only 93 of the 138 patients were finally included in this study because of the quality of information. They were 50 women and 43 men, aged 57.2 +/- 12.6 years. METHODOLOGY: The ambulatory blood pressure was recorded by oscillometric method (Spacelab monitor). The carotid artery were studied by echography and doppler. RESULTS: Carotid lesions in hypertensive patients didn't differ significantly when ambulatory systolic blood pressure increased (147,1 mmHg vs 145.2 in the day, and 135.5 mmHg vs 131.7 in the night; ns); Ambulatory diastolic blood pressure was lower during the day when carotid lesions where present (86.5 mmHg vs 93.2; p < 0.05). Ambulatory diastolic blood pressure decreased also with age; Ambulatory pulsed blood pressure increased when carotid lesions where present (59.3 mmHg vs 52.8 in the day and 58 mmHg vs 51.7 in the night; p < 0.05). Ambulatory pulsed blood pressure increased also with age and body mass index. CONCLUSION: This results suggest a predictive character of the pulsed pressure measure on the existence of carotid artery lesions in hypertensive patients and that a non invasive study of the carotid artery is opportune when pulsed pressure ambulatory measure is high.

[Pulmonary embolism and anaphylactic shock caused by rupture of a hepatic hydatid cyst]. / Embolie pulmonaire et choc anaphylactique par rupture d'un kyste hydatique hépatique.

A 44 year old man was admitted to hospital as an emergency for shock associated with giant urticaria and atrial fibrillation. Angiography showed pulmonary embolism, and an image suggesting a hydatid cyst of the liver was observed by echocardiography in the sub-costal view, confirmed by liver ultrasonic scan and serology. After treatment with Albendazole, the cyst was removed surgically and histology showed the characteristic appearances of hydatid disease. The final diagnosis was rupture of a hydatid cyst into a sub-hepatic vein with anaphylactic shock and pulmonary embolism.

[Left ventricular hypertrophy and blood pressure variability during rest and ambulatory monitoring in the hypertensive patient]. / Hypertrophie ventriculaire gauche et variabilité de la pression artérielle au repos et en ambulatoire chez l'hypertendu.

To study the relationship between assessment of blood pressure (BP) variability measured by continuous measurement (Finapres) or discontinuous ambulatory (ABPM Spacelabs) in 70 untreated essential hypertensive subjects (mean age 51 +/- 12) and their relationship with the development of left ventricular hypertrophy (LVH). There is no relationship between the BP variability measurements either by Finapres nor by ABPM. Multiple regression analysis show that ambulatory systolic BP variability (standard deviation) and resting BP variability (spectral analysis of SBP in the medium frequency band 0.1 Hz) are related to LVH index when we take into account age and BP difference (to explain LVH) (p < 0.001) ABPM SBP variability increase with LVH, while resting SBP measurement of BP variability (Mayer waves) significantly decreased. The study points to the different role of BP variability measurements in the mechanisms related to left ventricular hypertrophy and to the interest of continuous BP resting spectral analysis measurements.

[Evaluation of prognosis and myocardial ischemia using thallium in myocardial tomoscintigraphy]. / Evaluation du pronostic et de l'ischémie myocardique par la tomoscintigraphie myocardique au thallium.

Thallium scintigraphy holds a unique position amongst the methods available for evaluating the prognosis of coronary patients: it enables quantification of underperfused myocardium and evaluates already constituted ventricular damage (irreversible necrosis) and areas at risk of future coronary events (viable but ischemic myocardium). In a series of 1,926 patients who underwent exercise stress or dipyridamole Thallium myocardial scintigraphy for angina pectoris and followed up fort an average of 34 months, the following features were observed: the long-term prognosis in patients with normal myocardial scintigraphy (715 patients) was identical to that of a normal population of the same age (0.11% cardiovascular deaths per year) whereas the cardiovascular mortality was 15 times higher in cases with a pathological scintigraphy: finally, the long-term prognosis (cardiovascular deaths, infarcts or secondary revascularisation) was directly related to the severity of the initial lack of Thallium uptake. This method was used to assess the prognosis and evaluate the myocardial ischaemia in 75 patients who underwent complete surgical revascularisation fort ischaemia, 50 of whom had previous myocardial infarction: all patients had at least one arterial bypass graft: 39% of the myocardium was underperfused before revascularisation; this procedure reduced by 80% (p < 0.0001) the zones of reversible underperfusion but also zones of irreversible underperfusion by 17% (p = 0.04). The results were particularly impressive in patients who underwent revascularisation with an arterial pedicle (left and right internal mammary, gastroepiploic alone or in association) as 91% of the ischemic territories recovered on average 13 days after revascularisation.(ABSTRACT TRUNCATED AT 250 WORDS)

[Evaluation of the aging change in cardiac autonomic nervous system by automated clinical measurement]. / Evaluation de l'altération du système nerveux autonome cardiaque avec l'âge par mesure clinique automatisée.

The object of this study was to establish normal values for age of clinical tests of autonomic nervous system activity based on an automatic measuring system. Ninety-seven subjects (50 M/47 F) aged 20 to 85 years (average 45 +/- 13 years) with a normal clinical examination and no medication were included in the study. The blood pressure (BP) and heart rate (HR) were measured continuously with the Finapres system. After a resting period, the BP and HR were measured continuously in 5 different situations: dorsal decubitus position for 7 minutes; on getting up actively in less than 3 seconds and for 9 minutes in the upright positions, during deep breathing at 6c/min and Valsalva manoeuvre during a handgrip test at 30% of maximal voluntary strength for 3 minutes. A specific programme (ISN-CNRS) initiated the calculations of the test and performed direct and crossed spectral analysis in the lying and standing positions. The average BP was 120 +/- 18/66 +/- 11 mmHg and HR was 67 +/- 9 b/min. A negative linear correlation was observed with age with respect to the 3 tests investigating vagal activity: 30/15 ratio, spontaneous variations of respiration and HR, ratio of HR at the end of Valsalva with r = -0.43, r = -0.60, r = -0.34 (p < 0.001). The other two tests: variation of systolic BP 1 min 30 after standing and variation of diastolic BP during the handgrip did not change with age.(ABSTRACT TRUNCATED AT 250 WORDS)