Contribution of head-up tilt testing and ATP testing in assessing the mechanisms of vasovagal syndrome: preliminary results and potential therapeutic implications.

BACKGROUND: In patients with vasovagal syndrome, head-up tilt testing may reproduce symptoms generally associated with vasodepression. Recent research suggests ATP testing identifies patients with abnormal vagal cardiac inhibition. This preliminary study examined the joint contribution of both tests in identifying underlying mechanisms in the general population with vasovagal syndrome. METHODS AND RESULTS: Both tests were performed in random order during 1 session and outside of predominant sympathetic periods in 72 patients hospitalized for syncope (n=56) or presyncope (n=16) for whom no cardiac or extracardiac cause was found. For passive and isoproterenol-provocative tilt testing by standard protocol, reproduction of symptoms defined a positive test. The ATP test consisted of injecting ATP 20 mg IV at bedside, continuously monitoring ECG and blood pressure; a vagal cardiac pause >10 seconds defined a positive test. For most patients (64%), >/=1 test was positive. Of the 41 patients (57%) with a positive tilt test (either passive or provoked by isoproterenol), 32% had cardiac disease; none had significant bradycardia (<50 bpm). Of the 8 patients (11%) with a positive ATP test, 62% had cardiac disease; the probability of a positive result increased with age (P=0.015). Both tests were positive in 3 patients and negative in 26 patients; the tilt and ATP test results were uncorrelated (P=0.28). CONCLUSIONS: Results suggest tilt and ATP tests individually and jointly determine the mechanism of vasovagal symptoms in most patients and that vagal cardiac inhibition increases with age.

[The adenosine-5'-triphosphate (ATP) test: a diagnostic tool in the management of syncope of unknown origin. Basic and clinical aspects]. / Apport du test à l'adénosine-5'-triphosphate (ATP) dans l'évaluation diagnostique et l'approche therapeutique des syncopes d'origine indéterminée (vasovagale ou neurocardiogénique).

The prevalence of syncope increases in elderly population. An inappropriate reflex reaction of the autonomous nervous system in specific circumstances is responsible for symptoms in more than 50% of cases. These neurocardiogenic or vasovagal syncopes are due to a vasoplegia or to a cardio-inhibitory reflex or to the association of both mechanisms. Reproducing the symptoms may contribute to identify the responsible mechanism of syncope; this objective is partly reached by the head-up tilt test--a provocative test--which reproduces symptoms in about half of the cases, mainly by provoking a severe vasodilation with fall of blood pressure. On the opposite, the ATP test (20 mg i.v. bolus)--a descriptive test--provokes a strong cardio-inhibitory reflex independent from external factors like body position but it must be undertaken in a calm environment for preventing any anticipative sympathetic reaction. The test is considered positive if ATP produces a cardiac pause longer than 10 seconds and related symptoms are not taken into account for assessing the final result. ATP test positivity increases with age and with the presence of cardiac diseases. Permanent dual chamber pacing at 70 bpm has been shown to reduce significantly the syncope recurrences in patients with positive ATP test and to have no influence on patients with a negative test. The use of ATP test should be extended to all syncope screening. Its positivity identifies a group of patients in whom the mechanism of the syncope is susceptible to be improved by a permanent dual chamber pacing.

Acute and long-term efficacy of perindopril in severe chronic congestive heart failure.

To assess the short- and long-term hemodynamic efficacy of perindopril, 15 patients (12 men and 3 women) diagnosed with congestive heart failure were treated with oral perindopril (4 mg daily) for 3 months in association with digitalis and diuretic maintenance therapy. Patients were in New York Heart Association (NYHA) functional classes III and IV. Underlying cardiopathy was ischemic (6 patients), hypertensive (5 patients), valvular (2 patients), and dilated cardiomyopathy (2 patients). Hemodynamics, angiotensin-converting enzyme (ACE) activity, and perindoprilat (the active metabolite of perindopril) blood titration were measured at 2 periods. Acute assessment was performed over 2 titration days on oral perindopril 2 mg (day 1) and 4 mg (day 2); measurements were performed at rest and at 0, 1, 4, 6, 8, 12, and 24 hours. Chronic assessment was performed after 3 months of treatment with oral perindopril, 4 mg daily. During the study, 1 patient withdrew due to low systolic blood pressure (< 100 mm Hg) and 3 severely impaired patients died due to a worsening of heart failure during the study. Among the 11 remaining patients, 6 were symptomatically improved. On 4 mg perindopril administration, hemodynamic improvement was similar for peak values at both day 2 and at 3 months. At day 2, compared with baseline, cardiac index increased by 21% (p < 0.05) and pulmonary capillary wedge pressure (PCWP) and mean arterial pressure (MAP) decreased by 54% and by 21%, respectively (p < 0.01). Similarly, at 3 months, cardiac index increased by 37% (p < 0.001) and PCWP and MAP decreased by 41% and 19%, respectively (p < 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)

Acute pulmonary oedema: preliminary results of a randomized trial of the intravenous phosphodiesterase inhibitor, enoximone, vs conventional therapy.

The purpose of this open study was to compare the effects of enoximone and conventional therapy in 44 patients with acute pulmonary oedema. In this preliminary report, 22 patients were randomly assigned to the enoximone group (1 mg/kg bolus, every 8 hours for 48 hours) and 22 patients to conventional therapy (frusemide, nitrates, dopamine-dobutamine). Patients were assessed clinically at 0, 1, 2, 24 and 48 hours by the change in their Killip-Kimball score, dyspnoea, pulmonary rales, blood pressure, diuresis, requirement for additional therapy and/or death. Patient characteristics were similar except for distribution of the sexes. Improvements of each clinical parameter seemed more marked in the enoximone group, except during the first hour (due to the diuretics). The general course of the disease was more favourable in the enoximone group (17 cases vs 11 in the conventional therapy group), in which enoximone used alone was sufficient to normalize the haemodynamic variables. On the other hand, in the conventional therapy group, it was necessary to institute enoximone therapy in 9 cases. With the dosage used, enoximone appeared to be at least as effective as conventional therapy in acute pulmonary oedema. Moreover, no side-effects or tachyphylaxis appeared during the hospital assessment.

Sustained intra-atrial reentrant tachycardia. Electrophysiologic study of 20 cases.

Twenty cases of sustained tachycardia due to intra-atrial reentry were investigated in patients aged 17 to 80 years (mean 47). The average frequency of the tachycardia was 128.6/min (extremes 95 and 180). Three modes of onset of the tachycardia were observed: atrial extra-stimulus (19 times), progressively accelerated atrial pacing (9 times) and atrial escape beat (10 times). The tachycardia was stopped in all cases by a premature stimulation. When spontaneous, the termination was either sudden (10 times) or preceded by a progressive slowing (9 times) or an alternating phenomenon of long-short cycle (13 times). Precise atrial mapping allowed to localize the first atrial depolarization less frequently in the sinus node area (1 case) than in the mean right atrium (21 cases), the low right atrium (2 cases), the interatrial septum (2 cases), and the left atrium (4 cases). The macroscopic size of the reentry circuit was demonstrated in only 3 cases. A junctional reentry was accurately ruled out in all cases thanks to the existence of a second or third-degree AV or VA black, or by studying the sequence of retrograde atrial activation. A true junctional reciprocating tachycardia was associated with the intra-atrial reentry in 2 cases.

[Orgainc tricuspid pathology in rheumatic valvulopathies].

Surgical observations show that organic tricuspid lesions are not uncommon: 3.2% among cases of valvular surgery, 9.5% among patients with combined mitral and aortic replacements. Pure stenosis is relatively rare (7 cases) but easy to diagnose: this lesion plays a protective role on pulmonary parenchyma. There is no symptom due to congestive lungs and few pulmonary post-operative complications among these patients. Organic tricuspid insufficiency, isolated or associated to stenosis is more frequent (18 cases) but more difficult to diagnose before surgery. There seems to be no protection of the pulmonary circulation. Pulmonary arterial hypertension, clinical and radiological features of congestive lungs and post-operative pulmonary complications are usual.

[Intravenous enoximone versus conventional treatment in acute lung edema. Preliminary results of a randomized study]. / Enoximone administré par voie intraveineuse contre traitement conventionnel dans l'oedème aigu du poumon. Résultats préliminaires d'une étude randomisée.

The aim of this open study was to compare the efficacy of Enoximone and conventional treatment in 44 patients with acute pulmonary edema. At the time of this interim analysis, 22 patients had received Enoximone (1 mg/kg by rapid intravenous injection every 8 hours for 48 hours) and 22 were given conventional treatment (furosemide, nitrates, dopamine-dobutamine). The treatment schedules were randomised. Clinical data was obtained at 0, 1, 2, 24 and 48 hours and evaluated using the Killip-Kimball score, dyspnoea, pulmonary rales, the need for additional therapy and patient mortality. The patients in the two groups were comparable in all clinical features except the sex ratio. The improvement of all clinical criteria of evaluation seemed to be greater in the Enoximone group, except during the first hour of treatment (due to the action of diuretics). The overall outcome was better in the Enoximone group (17 favourable responses compared to 11 in the group receiving conventional treatment). Normalisation of haemodynamic parameters was observed only with Enoximone. In addition, it became necessary to administer Enoximone to 9 patients in the conventional treatment group. At these doses, Enoximone was at least as effective as conventional treatment of acute pulmonary edema. What is more, no secondary effects or tachyphylaxis were observed during the period of hospital treatment.

[Treatment of junctional paroxysmal tachycardia, without patent Wolff-Parkinson-White syndrome, by sectioning an accessory Kent-His bundle]. / Traitement d'une tachycardie paroxystique jonctionnelle sans syndrome de Wolff-Parkinson-White patent par section d'un faisceau de Kent gauche inapparent

The authors report the case of a patient suffering from a Bouveret's tachycardia without syndrome of Wolff-Parkinson-White. The analysis of the tachycardic spells however showed that during a reciprocal crisis, the circuit went through a left accessory ventriculo-atrial bundle, functioning only in the reverse direction. This accessory bundle was successfully cut by the surgeon, following the procedure of wide atrioventricular desinsertion as described by the authors of Duke University for the surgical treatment of the Wolff-Parkinson-White syndrome.

[Acute thrombosis of mitral Starr prosthesis. Value of color coded two-dimensional doppler echocardiography]. / Thrombose aiguë de prothèse de Starr mitrale. Intérêt de l'échocardiographie-doppler bidimensionnelle à codage couleur.

In a case of acute thrombosis on mitral Starr valve two-dimensional doppler-echocardiography rapidly showed that parts of the transprosthetic jets had disappeared, while conventional continuous wave doppler ultrasound confirmed the presence of a severe haemodynamic obstacle. With colour-coded doppler ultrasound, there only remained a jet that was parallel to the posterior wall of the left ventricle. This jet was of unusual pattern, with the presence of turbulence and high velocities in aliasing colour. The effectiveness of a thrombolytic treatment was demonstrated by the reappearance of the missing diastolic jets with return to normal velocities. Comparison between a post-thrombolysis colour-coded doppler examination and a reference examination confirmed that the valve was now functioning normally. Thus, while conventional doppler recordings accurately quantify prosthetic dysfunctions leading to stenosis, two-dimensional doppler recordings rapidly provide an anatomical information. By showing changes in the transprosthetic jets they indicate the precise location and extent of valve obstruction.

[The value of temporary electrosystolic pacing for treating low output in posterior necrosis with adiastole]. / Intérêt de l'entraînement électrosystolique temporaire pour traiter le bas débit des nécroses postérieures avec adiastolie.

Early catheterisation was performed in 27 patients with an acute inferior myocardial infarction less than 3 days old complicated by signs of low output with right ventricular dysfunction. All patients had hemodynamic criteria of adiastole (PCP = 14.9 +/- 31 mmHg and LVEDP = 14.1 +/- 4.7 mmHg) with low cardiac output (CI = 1.41 +/- 0.32 l/min/m2). An atropine resistant bradycardia was characteristic (HR = 65 +/- 17.2/min) due to advanced or complete AV block (11 cases), sinoatrial block (3 cases, one with right atrial standstill) or sinus/parasinus rhythm (13 cases) inappropriate to the severity of their hemodynamic state. Although the prognosis based on the discriminating linear function FI = -0.427 + 0.00121 LVW - 0.00125 TPR was initially poor and predicted the death of 21 out of the 27 patients at one month, the outcome was usually favourable and only 8 patients died during the first month. Fifteen patients were treated by temporary endocavitary RV pacing. As the heart rate was increased from 53.8 +/- 11.2 to 92.4 +/- 4.9/min, the CI rose from 1.35 +/- 0.26 to 1.85 +/- 0.46 l/min/m2 (p less than 0.001) with a fall in SI from 26.7 +/- 8.3 to 20.1 +/- 5.6 ml/beat/m2 (p less than 0.005). The results were even further improved in 3 cases by sequential A-V pacing. The observed hemodynamic improvement continued during the period of pacing providing volumic expansion maintained LVEDP above 10 mmHg.(ABSTRACT TRUNCATED AT 250 WORDS)

[The atrial arrhythmia syndrome of vagal origin]. / Syndrome d'arythmie auriculaire d'origine vagale.

Having observed 18 cases, the authors describe a syndrome of recurrent paroxysmal atrial arrhythmia which was very homogeneous from the clinical and ECG point of view. It was usually found in middle aged males, with no demonstrable underlying heart disease, whose disorder of intra-atrial conduction occurred during sinus rhythm. The condition developed slowly over the course of years towards a maximum incidence of several short daily attacks of an arrhythmia which alternated between an atrial fibrillation and atrial flutter. Vagal overactivity is the precipitating cause of these attacks which are usually not completely nocturnal. The condition never progressed to sino-atrial block nor to permanent fibrillation. The beginning of each attack, often heralded by atrial coupling with a long enough interval to cause re-entry, is accompanied by slowing of the sinus rate down to the threshold level. The vagal effect of shortening the action potential and refractory period is recognised to be non-homogeneous in the atrial wall, and suggests a re-entry mechanism rather than hyper-excitability. This would explain the usual resistance of atrial arrhythmias of vagal origin to digitalis, beta blockers and quinidine. Amiodarone alone is usually effective because of the prolongation of the action potential which it causes. In 5 particularly resistant cases a good clinical result was obtained by the insertion of an atrial pacemaker with a fairly rapid rate.

[Anti-arrhythmia effect of long-term encainide in chronic ventricular extrasystole]. / Etude de l'effet anti-arythmique de l'encaïnide au long cours dans l'extrasystolie ventriculaire chronique.

The long term efficacy and tolerance of encainide were studied in 48 patients with chronic/ventricular extrasystoles (VES) treated for 6 months. Holter monitoring was performed before treatment and at each dose increment (75 mg/day; 150 mg/day and 225 mg/day) during the first week of titration, and then after 1 month and 6 months of treatment. The dose administered in the long-term study corresponded to the minimum effective dose during the titration phase (the dose which reduced the number of VES/24 hours by at least 75%). The average number of VES/hour decreased significantly from 480.6 before treatment to 2.0 at the end of the study. The frequency of episodes of ventricular tachycardia decreased significantly during treatment. The commonest side effects were vertigo, visual disturbances and headaches. Treatment was interrupted because of side-effects or inefficacy in 6 patients. The surface ECG showed significant lengthening of the PR, QRS and QTc periods and encainide appeared to have aggravated the ventricular arrhythmias of 4 patients receiving 200 mg/day. The plasma concentrations of encainide and its two principal metabolites were measured during the titration phase, at 1 month and after 6 months of treatment. 15.6 per cent of patients were slow and 84.4% of patients were rapid metabolizers. The wide individual variations of plasma concentrations and the absence of correlation between the plasma concentrations of encainide and its metabolites and the antiarrhythmic effect suggest that the compound and its metabolites play a role in the antiarrhythmic effect of the drug.

[A randomized double-blind trial comparing cibenzoline and disopyramide in the prevention of recurrences of atrial tachyarrhythmia]. / Etude randomisée en double aveugle comparant la cibenzoline et le disopyramide dans la prévention de récidives de tachyarythmies atriales.

The aim of this multicenter, randomised, double-blind trial was to compare the efficacy and tolerance of oral disopyramide (D: 250 mg slow release twice daily) compared with cibenzoline (C: 130 mg twice daily) in the prevention of recurrences of atrial arrhythmias over a 6 month period. Sixty patients (mean age: 62 +/- 14 years; 37 men, 23 women; cardiac disease in 60% of cases) were randomised to two groups: C (N = 31) and D (N = 29). The commonest arrhythmia was atrial fibrillation (83%). The arrhythmia was recent (< 3 months) in 41% of patients and present for more than one year in 38% of patients. Sixteen patients of Group C (52%) and 11 of Group D (38%) had recurrences after an average of 79 +/- 58 days for Group C and 58 +/- 40 days for Group D (p = NS). The probability of absence of recurrence at 6 months was 36 +/- 11% in Group C and 55 +/- 10% in Group D (p = NS). Four patients in Group C (13%) and 13 patients in Group D (45%) had at least one unwanted side-effect (p = 0.009). Treatment was stopped because of side-effects in 2 patients in group C (6%) and 6 patients in Group D (21%). These results show that cibenzoline has a comparable efficacy for the prevention of recurrence of atrial tachyarrhythmia and is significantly better tolerated than disopyramide. This differences is mainly related to the marked anticholinergic effects of disopyramide.

[Interstitial pulmonary involvements in polymyositis and dermatopolymyositis. Apropos of 3 cases. Review of the literature]. / Atteintes pulmonaires interstitielles des polymyosites (PM) et dermatopolymyosites (DP). A propos de 3 observations. Revue de la littérature.

The authors report 3 cases of myositis associated with pulmonary lesions that preceded or succeeded the muscular disorder. In one of these cases, which was particularly difficult to diagnose, the patient's serum was positive for the anti-Jol antibody. These 3 cases have encouraged the authors to review the literature with particular attention to the diagnostic approach, the latest physiopathological data and the therapeutic basis of the "specific" pulmonary lesions associated with polymyositis and dermatomyositis.

[Interstitial pulmonary involvement of polymyositis and dermatomyositis. Apropos of 3 cases. Review of the literature]. / Atteintes pulmonaires interstitielles des polymyosites (PM) et dermatopolymyosites (DP). A propos de 3 observations. Revue de la littérature.

The authors report 3 new cases of myositis associated with pulmonary lesions that preceded or succeeded the muscular disorder. In one of these cases, which was particularly difficult to diagnose, the patient's serum was positive for the anti-Jo1 antibody. These 3 cases have encouraged the authors to review the literature with particular attention to the diagnostic approach, the latest physiopathological data and the therapeutic basis of the "specific" pulmonary lesions associated with polymyositis and dermatomyositis.

Symptoms during ATP-test under pacing: impact on syncope recurrence and prediction from the ATP-test without pacing.

Syncope recurrence in patients with positive ATP-test who underwent permanent pacemaker implantation is suspected to be related to vagal vasodilatation. We studied symptoms during ATP-test in 38 temporary paced patients. Among patients with positive ATP-test who underwent permanent pacemaker implantation (N = 14), the only one patient who recurred during follow-up was symptomatic during the initial paced ATP-test. Symptoms during paced ATP-test were well predicted by a higher blood pressure (BP) drop during standard ATP-test (i.e. without pacing) (Area under ROC curves > 0.70 for all BP parameters except for relative diastolic BP drop). Moreover, BP drop during standard and paced ATP-test were significantly correlated (all p ≤ 0.03). Thus, a higher BP drop measured during ATP-test without pacing might help identify patients who would experience recurrences due to vasodilatation under permanent pacing.