Characterization of different subsets of atrial fibrillation in general practice in France: the ALFA study. The College of French Cardiologists.

BACKGROUND: The clinical presentation and causes of atrial fibrillation (AF) in the 1990s may differ from AF seen 2 to 3 decades ago. It was the objective of this prospective study to characterize various clinical presentations and underlying conditions of patients with AF observed in general practice in France. METHODS AND RESULTS: The study population comprised 756 patients (19 to 95 years of age) with electrocardiographically documented AF subdivided into paroxysmal (<7 days), chronic (last episode >1 month) and recent onset AF(persistent >7 days and<1 month). Symptoms were present in 670 patients (88.6%). The relative prevalences of paroxysmal, chronic, and recent onset AF were 22.1%, 51.4%, and 26.4%, respectively. Cardiac disorders, present in 534 patients (70.6%), included hypertension (39.4%), coronary artery disease (16.6%), and myocardial diseases (15.3%) as the most common. Rheumatic valvular disease represented a common cause in women (25. 0%) but not in men (8.0%). The paroxysmal group differed by a high percentage of palpitations (79.0%) and a low percentage of underlying heart disease (53.9%). With a mean follow-up of 8.6+/-3.7 months, 28 patients (3.7%) died, including 6 fatal cerebrovascular accidents. Among the 728 patients who survived, congestive heart failure occurred in 30 patients (4.1%), and embolic complications occurred in 13 patients (1.8%). In the paroxysmal AF group, 13 patients (8.0%) developed chronic AF and 51 (31.3%) had AF recurrences. At the time of follow-up, 53 patients (14.3%) from the chronic AF group and 108 patients (55.7%) from the recent onset AF group were in sinus rhythm. CONCLUSIONS: This large-scale study establishes the current demographic profile of out-of-hospital patients with AF and highlights some of the changes that have occurred in the past decades, including a particular shift in cardiac causes toward nonrheumatic AF. This study also demonstrates significant differences between various subsets of AF.

Comparison of oral loading dose of propafenone and amiodarone for converting recent-onset atrial fibrillation. PARSIFAL Study Group.

In patients with recent-onset atrial fibrillation (AF), restoration of sinus rhythm is considered to be the first-line therapeutic option. Although this conversion might be obtained by direct-current shock or intravenous antiarrhythmic drugs, administration of an oral loading dose of class I or III antiarrhythmic drugs is more simple and convenient. This prospective, randomized, multicenter study compares the time to conversion to sinus rhythm obtained with an oral loading dose of propafenone or amiodarone. Patients with recent-onset AF (<2 weeks), without contraindications for the 2 drugs, were randomly assigned to be treated with propafenone (600 mg for the first 24 hours and if necessary a repeated dose of 300 mg for 24 hours) or amiodarone (30 mg/kg for the first 24 hours and if necessary a repeated dose of 15 mg/kg for 24 hours). Exact conversion time during the first 24 hours was determined by Holter monitoring. In each treatment group 43 patients with the same baseline characteristics were included. The median time for restoration of sinus rhythm was shorter (p = 0.05) in the propafenone (2.4 hours) than in the amiodarone (6.9 hours) group. After 24 hours (56% in the propofenone and 47% in the amiodarone group) and 48 hours, the same proportion of patients in the 2 groups recovered sinus rhythm (no serious adverse events were noticed). Thus, oral loading dose of propafenone or amiodarone was safe with a similar conversion rate of recent-onset AF. Propafenone had a faster action.

[Ebstein's disease associated with Fallot's tetralogy. Apropos of a familial case, review of the literature, embryologic and genetic implications]. / Maladie d'Ebstein associée à une tétralogie de Fallot. A propos d'une observation familiale, revue de la littérature, implication embryologique et génétique.

Ebstein anomaly is a rare congenital cardiac malformation, representing 0.3 p. 100 of all congenital heart disease. The authors report a case of a child with Ebstein anomaly associated with tetralogy of Fallot, whose father had an apparently simple Ebstein anomaly. The association of Ebstein-Fallot is extremely rare with only 5 previously reported cases in the literature. The association Ebstein-VSD-pulmonary stenosis is more frequent (13 cases), whilst the association Ebstein-isolated VSD (33 cases) and Ebstein-pulmonary stenosis/atresia (38 cases) are relatively common. Other very varied associations have also been described. Atrial septal defect is practically an integral part of Ebstein anomaly with an ostium secundum or patent foramen ovale in 51 to 80 p. 100 of cases. The possibility of 2 subjects in the same family with Ebstein anomaly is far from negligible. A review of the literature revealed 7 other reported "pairs". A certain number of other cases also demonstrate the association of Ebstein anomaly with another congenital cardiac malformation in the same family, usually a VSD or tetralogy of Fallot. Our familial case raises the question of a possible embryological link between Ebstein anomaly and tetralogy of Fallot. Our experimental embryological studies also suggest the presence of a common denominator between these two conditions.

[Macrodystrophia lipomatosa. Angiographic aspects (author's transl)]. / Macrodystrophie lipomateuse. Aspect artériographique.

A new case of this unusual entity is reported. The patient, male aged 43 has an hypertrophy of the first and second left fingers. Radiographic examination shows bony overgrowth and marked soft tissue thickening. Arteriography did not show any evidence of angioma or arteriovenous fistula. Histologic examination shows deposits of fat in soft tissue thickening. Macrodystrophia lipomatosa is a rare disease, usually confined to one or two digits of the hand, and sometimes of the foot. A dysembryoplasic aetiology could be sustained, and this entity is very close from others bone or soft-tissue hamartomas.

[Efficacy and tolerability of trandolapril in overweight hypertensive patients]. / Efficacité et tolérance du trandolapril chez l'hypertendu en surpoids.

An open multicentre study, performed in 340 overweight (body mass index: BMI > or = 25), hypertensive (95 mmHg < or = DBP < 115 mmHg) patients, evaluated the clinical and metabolic safety of trandolapril and confirmed its antihypertensive activity. After a two-week washout period, the patients received trandolapril 2 mg as a single morning dose for 12 weeks. Doubling of the dosage was authorized after the first four weeks when the DBP remained higher than 90 mmHg with a fall in DBP < 10 mmHg. Of the 287 patients who completed the study, 15.1% had to receive a double dose of trndolapril during the second treatment period. After four weeks of treatment, SBP was decreased by 18.6 mmHg, DBP was decreased by 13.4 mmHg and 63.1% of patients were controlled. After three months of treatment, SBP was decreased by 23.3 mmHg, DBP was decreased by 16.8 mmHg and 84.7% of patients were controlled. Subgroup analysis, according to the BMI (BMI > or = or < 30), showed that the fall in blood pressure was identical regardless of the BMI; the proportion of patients treated with a double dose of trandolapril was also independent of the BMI. A second subgroup analysis, according to the waist/hips ratio, did not reveal any difference according to the android or gynoid profile of excess weight. Twelve patients (3.9%) dropped out of the trial because of adverse events, 10 of which were attributable to treatment; 6.5% of patients reported an adverse effect attributable to treatment. Laboratory assays performed before and after three months of treatment demonstrated the very good metabolic safety profile of trandolapril, in view of the slight but significant reduction of total cholesterol, triglycerides and blood glucose. However, an average weight loss of one kilogram was reported. The global safety was considered to be good or excellent by the investigators in 94.8% of cases.

[Electrocardiographic evaluation of anti-ischemic effect of verapamil during angioplasty]. / Evaluation électrocardiographique des effets anti-ischémiques du vérapamil en cours d'angioplastie.

The anti-ischemic and cardioprotective effects of various angina drugs have been evaluated during angioplasty. This special situation of transitory regional ischemia was used to test verapami given by intra-coronary injection in 15 patients undergoing balloon dilatation of the left anterior descending artery, suffering from stable angina and with normal left ventricular kinetics. Each patient serving as his own control, parameters indicating oxygen consumption and clinical and electrocardiographic (ST segment changes) markers were measured during two successive inflations. Continuous monitoring of comparative variations between a first inflation without treatment and a second inflation after intra-coronary administration of 1 mg of verapamil revealed, following 60 seconds of ischemia, the absence of any change in heart rate, a moderate fall in mean blood pressure (101.7 as against 96.8 mmHg, p = 0.033) and a notable 60% reduction in the amplitude of maximal ST depression (5.07 +/- 3.08 mm as against 2.07 +/- 1.44 mm, p = 0.0002). These results confirm the anti-ischemic properties of verapamil, the action of which is based upon an indirect peripheral vasodilator model but also on a probable direct cardioprotective effect on anoxic myocardial regions.

[Long-term prognosis of resuscitation after cardiocirculatory arrest in coronary disease patients]. / Pronostic à long terme des réanimations après arrêt cardio-circulatoire chez les coronariens.

In France alone, coronary diseases are responsible for about 30 000 sudden deaths each year. In 60 to 90% of the cases cardiac arrest (CA) is due to ventricular fibrillation. The overall survival rate after CA is 66-92% at 1 year and 67-87% at 2 years. The long-term prognosis is more favourable when CA occurs during a recent infarction. Frequent, polymorphous, paired or consecutive ventricular extrasystoles, three-vessel coronary lesions, an ejection fraction lower than 0.30 and repetitive ventricular response to electrophysiological stimulation indicate severe myocardial damage and suggest that CA might recur. The preventive treatment of recurrent CA has not yet been fully established. Beta-blockers should probably be used widely, but the protective effect of other anti-arrhythmic agents is more questionable. Coronary artery bypass reduces mortality in patients who survive CA but has not been proven to lower the recurrence rate.

[Effects of sustained-release verapamil on hemodynamics and renal function of patients with moderate to severe chronic renal failure]. / Effets du vérapamil à libération prolongée sur l'hémodynamique et la fonction rénale de patients en insuffisance rénale chronique modérée à sévère.

The effects of long-acting verapamil (240 mg/24 h) on blood pressure, systemic haemodynamic parameters, left ventricular function, renal blood flow, and blood and urinary chemistries were measured in hypertensive patients with moderate or severe chronic renal failure. The treatment was proposed for a 4-week period after a 2-week placebo period. In the 15 patients studied, lower arterial pressure resulted from decreased peripheral vascular resistances. Cardiac parameters were not found to change during treatment. The lowered blood pressure had non effect on glomerular filtration which remained unchanged throughout the 4-week treatment. Renal vascular resistances greatly decreased and renal blood flow increased significantly. No major change in blood or urine chemistries were seen excepting uric acid for which a significant decrease in the blood level correlated with significantly increased urinary excretion. Finally, the left ventricle function curves were unchanged as was the baroreceptor circuit. Long-acting verapamil was thus found to be effective and well tolerated in patients with chronic renal failure.