[Enoximone: hemodynamic effect in patients with cardiac insufficiency]. / Enoximone: effet hémodynamique chez l'insuffisant cardiaque.

Enoximone, a phosphodiesterase inhibitor, is a positive inotropic agent with direct vasodilator properties. Its acute effects after I.V. administration and the possibility of oral relay were studied in 14 patients (13 men and 1 woman), 40 to 78 years of age (mean 61 years) with Stage IV cardiac failure (NYHA Classification). Eleven patients had dilated cardiomyopathy, 2 had ischemic heart disease and 1 a dilated hypertrophic cardiomyopathy. The haemodynamic inclusion criteria were: cardiac index less than or equal to 2.2 l/mn/m2 and pulmonary capillary pressure greater than or equal to 18 mmHg. Patients with cardiogenic shock and severe renal or hepatic failure were excluded. The drug was administered as a bolus of 1 mg/kg followed by a continuous infusion of 5 to 15 g/kg/mn (average 8.9 +/- 2.6 for 7 to 72 hours; average 27 +/- 16 hours). Haemodynamic effects of I.V. administration: no change in heart rate, slight lowering of blood pressure, very significant reduction in right atrial and pulmonary capillary pressures, of pulmonary artery pressures, of arteriolo-capillary and systemic resistances and marked increase in cardiac output. General tolerance was excellent with no clinical secondary effects and no signs of hepatic, renal or haematological (platelets) toxicity. Cardiac tolerance was also excellent, no aggravation of preexisting arrhythmias. There was no immediate mortality. Oral relay was undertaken in 14 patients with a daily dose of 300 mg in 12 cases, 400 mg in 1 case and 500 mg in 1 case. Six patients underwent control haemodynamic evaluation on the 8th day: there were no signs of the haemodynamic improvement obtained by I.V. administration.(ABSTRACT TRUNCATED AT 250 WORDS)

[Long-term prognosis of spastic angina with normal or irregular coronary arteries. Apropos of 48 cases]. / Pronostic à long terme de l'angor spastique à coronaires normales ou irrégulières. A propos de 48 cas.

Forty-eight consecutive patients (37 men, 11 women, mean age 49 +/- 8 years) were followed up regularly for a mean period of 7 years. All presented with spontaneous angina, documented coronary spasm and no stenosis greater than 50 p. 100 at coronary arteriography. The first attack of pain had taken place 3 days to 9 years previously; exertion angina was also present in 47 p. 100 of the cases and severe arrhythmia in 17 p. 100. Treatment was based on calcium antagonists in doses and combinations that varied with the course of the disease. The follow-up period lasted from 16 to 122 months (mean 85 +/- 24 months). 3 patients are now known to be alive but were lost sight of after 12 to 21 months. Major cardiac complications were 1 death (2 p. 100) and 3 cases of myocardial infarction (6.6 p. 100). None of the patients died suddenly. 70 p. 100 of the remaining 41 patients became asymptomatic; angina persisted in 15 p. 100 and 14 p. 100 had episodes of severe angina but with remissions of at least one year. No predictive factor of functional deterioration or major cardiac complications could be elicited. The long-term prognosis of vasospastic angina in patients with little or no coronary stenosis is favourable, but there is a very small risk of myocardial infarction or death.

Long-term prognosis of medically treated patients with vasospastic angina and no fixed significant coronary atherosclerosis.

The clinical course of 48 consecutive patients with vasospastic angina and minor coronary atherosclerosis (no stenoses greater than 50%) was analyzed during an average follow-up period of 47 months. The study group consisted of 37 men and 11 women. Patients were treated with usual doses of calcium antagonists. One patient died (2%) and three had myocardial infarctions (6%). Seventy-one percent were asymptomatic or had infrequent angina; 13% had recurrences but had periods of remission lasting at least 10 months. Only 16% had persistent angina. None of the clinical or angiographic findings at the time of diagnosis were predictive of myocardial infarction or death, and they could not separate angina-free patients from those with recurrences. Thus, vasospastic angina without fixed coronary narrowing has a good prognosis despite the possibility of recurrences. However, there is a slight risk of myocardial infarction and death. This fact should be considered if there are plans to discontinue treatment.

[Permeability of venous aortocoronary bypasses one year after their implantation]. / Perméabilité des pontages veineux aorto-coronaires un an après leur implantation.

For a short-term evaluation of the patency of aortocoronary bypass vein grafts, 54 consecutive patients who underwent this operation alone were examined, irrespective of their functional state, 12.4 +/- 2.1 months after surgery. Examinations included coronary arteriography, selective opacification of the graft and ventriculography. The patients were 47 men and 7 women who had coronary arteriography for stable angina pectoris (22.4%) or a recent episode of unstable angina (59.3%) or a recent myocardial infarction (18.5%). Coronary arteriography showed one-vessel (5.5%), two-vessel (27.8%) or three-vessel (42.6) disease or stenosis of the main left coronary artery (24.1%). The mean number of distal anastomoses in multiple-vessel patients was 2.6. Peri-operative mortality was 1.04%, and the proportion of peri-operative electrocardiographic signs of necrosis was 11%. At the time of control examination, 82% of the patients had few or no symptoms, and 88% were improved by at least one functional class. 79% (97/123) of distal venous anastomoses were patent. All anastomoses were patent in 59% (22/54) and all were occluded in 7% (4/54) of the patients. Localized stenosis of the graft was found in 11% and diffuse stenosis in 4% of the cases. The patency of vein grafts was higher when the distal bed was of normal size than when it was small or poorly visualized at the initial angiography (85% vs 62%, p less than 0.01), or when the diameter of the artery bypassed was greater than 1.3 mm.(ABSTRACT TRUNCATED AT 250 WORDS)

Comparison of risk factors in vasospastic angina without significant fixed coronary narrowing to significant fixed coronary narrowing and no vasospastic angina.

To determine the importance of usual risk factors of coronary artery disease (CAD) in patients with coronary artery spasm, 40 patients with vasospastic angina (VA), normal or nearly normal coronary arteries and without previous myocardial infarction were compared with 2 control groups of 40 patients each, matched for age and sex: 1 group with CAD and 1 without heart disease. Ninety percent of patients with VA were cigarette smokers and 70% were heavy smokers (more than 20 cigarettes daily), compared with 53% and 33% in patients with CAD (p less than 0.001) and 30% and 15% in those without heart disease (p less than 0.001). Except for cigarette smoking, the risk factor profile of patients with VA appeared more like the profile of patients without heart disease than that of patients with CAD. The results suggest that cigarette smoking may play a role in CAD independent of atherosclerosis and possibly favoring coronary artery spasm.

[Unstable angina caused by monotruncular stenosis of the anterior interventricular artery (87 cases). Results of medical and surgical treatment]. / L'angor instable par sténose monotronculaire de l'IVA (87 cas). Résultats des traitements médical et chirurgical.

The aim of this study was to compare the medium-term results of medical therapy and aortocoronary bypass surgery in 87 patients selected on the following criteria: Clinical: unstable angina, defined as effort and/or resting angina appearing for the first time or increasing in severity within the previous 3 months, the last attack of chest pain occurring less than 8 days before admission to the Coronary Care Unit, with no signs of myocardial infarction before hospital admission and at coronary angiography. Coronary angiography: proximal isolated left anterior descending artery stenosis (greater than 70%). Thirty five patients were treated medically and 52 underwent coronary bypass surgery on the LAD artery: the results were compared at 18 and 24 months. Six patients were lost to follow-up, 2 from the medical group; the other 33 patients comprised group A. Four surgical patients were lost to follow-up, the other 48 patients comprised group B. The two groups had comparable clinical and epidemiological features. They differed in the incidence of hypertension which was more common in group A (p less than 0.01), in the better quality of the distal LAD artery in group B (p less than 0.01), and in the coexistence of less than 50% stenosis on the right coronary and left circumflex arteries which was commoner in group A (p less than 0.05). The mean follow-up period was comparable in the two groups (group A: 20.5 +/- 4.6 months; group B: 19.8 +/- 5.5 months).(ABSTRACT TRUNCATED AT 250 WORDS)

Coronary spasm and thrombosis associated with myocardial infarction in a patient with nearly normal coronary arteries.

A 37-year-old man presented with an evolving inferior myocardial infarction. Coronary angiography performed within 3 hours after the onset of the pain showed spasm of the right coronary artery and the presence of intracoronary thrombi. After resolution of spasm and the disappearance of thrombi, angiography revealed nearly normal coronary arteries. An ergonovine test was positive when the patient was not taking medication and became negative when he was taking diltiazem. The course was uncomplicated, and after 9 months the patient is free of angina.

Increased exercise tolerance and reduced electrocardiographic ischemia with diltiazem in patients with stable angina pectoris.

Diltiazem is a calcium slow-channel blocking drug that may be effective in the treatment of chronic stable angina pectoris. To evaluate the therapeutic efficacy 3 hours after a single oral dose of 120 mg, 12 men with chronic stable angina pectoris performed a maximal exercise test on a bicycle ergometer after ingesting either placebo or diltiazem administered in a double-blind fashion. During submaximal exercise at a fixed work load, diltiazem decreased the average heart rate response from 119 +/- 17 to 107 +/- 14 beats/min (p less than 0.01), systolic blood pressure from 182 +/- 15 to 175 +/- 15 mm Hg (p less than 0.05) and the rate-pressure product from 21.8 +/- 4.2 to 18.8 +/- 3.2 x 10(-3) units (p less than 0.01). The average submaximal work load at which significant ST-segment depression (0.1 mV) first appeared was increased from 355 +/- 142 to 525 +/- 143 seconds (p less than 0.01) after diltiazem. At peak exercise after diltiazem, the average depth of ST-segment depression in any one lead and the extent of myocardial ischemia observed in all 12 ECG leads were decreased (p less than 0.01), even though the average work load was increased by 29% (p less than 0.01). Peak heart rate, systolic blood pressure and rate-pressure product were similar with placebo and diltiazem. The plasma diltiazem concentration was 13.9 +/- 29 ng/ml 3 hours after ingestion and was significantly (p less than 0.05) related to the increased time to the onset of important ST-segment depression (r = 0.65) and to the decrease in the extent of myocardial ischemia observed in all 12 ECG leads (r = -0.61) compared with placebo. Thus, diltiazem is effective in treating chronic stable angina pectoris. It decreases myocardial oxygen requirements during upright exercise and appears to increase myocardial oxygen delivery.

[Coronary insufficiency caused by spasm with arteries injured slightly or not at all (31 cases)]. / L'insuffisance coronaire par spasme avec artères peu ou pas lésées (31 cas).

An epidemiological and clinical study was carried out on 31 patients with spasm of normal coronary arteries. The series comprised 24 males and 7 females aged 30 to 68 years (mean age: 48 years) with isolated resting chest pain (61 p. 100) or with resting and effort chest pains (39 p. 100). Their cardiovascular risk factors were compared to 735 unselected patients with coronary insufficiency undergoing coronary coronary angiography. Abnormalities of lipid metabolism (45 p. 100) and obesity (14 p. 100) were less common but there was a higher incidence of smoking (74 p. 100 compared to 48 p. 100). Sixteen patients had a psychological test: repressed aggressivity and severe anxiety were found in all patients, a state of separation coincided wtih the onset of the illness in 10 of the 16 patients. On admission, 13 patients presented with attacks of Prinzmetal variant angina, with myocardial infarction in 2 cases. Eighteen patients had non-invalidating angina with sporadic attacks. Coronary angiography was normal in 8 patients and showed lesions with less than 50 p. 100 narrowing in the other 23 patients. Mitral valve prolapse was found on left ventriculography in four patients. Exercise electrocardiography was positive in 7 out of 20 patients, and notably in those who had not had effort angina. All patients were treated with calcium antagonist drugs (25 Nifedipine, 6 Diltiazem), the efficacity of which was tested in 20 patients with a control ergometrine test. Thirty patients were followed up for 6 to 46 months (mean: 15 months). The exercise stress tests were repeated in the 7 patients with positive results before treatment and the results were negative in all cases. Twenty three patients were completely pain free or significantly improved, although 25 p. 100 of control tests remained positive (4/16). Six patients continued to have as much chest pain, and three had positive control tests. One patient with a negative control test developed acute myocardial infarction six months later in the territory of the spasm: during hospitalisation the ergometrine test became positive again.

[Arterial blood gas analysis in acute pulmonary embolism]. / La gazométrie artérielle dans l'embolie pulmonaire aiguë.

Arterial blood gases (pH, pO2, p CO2) were studied in 100 patients with documented pulmonary embolism (Group A), confirmed by pulmonary angiography (n = 51) or scintigraphy ( n = 49). The pO2 ranged from 32 to 97 mm Hg (average 60,5 +/- 13 mm Hg). Hypoxaemia was found in 97 cases and would therefore seem to be a reliable sign of pulmonary embolism. In the three cases in which it was absent, the embolism was small. Hypoxaemia was associated with hypocapnia and alkalosis in 91 cases. However, hypoxaemia was not a specific finding; it was also present in 49 patients with suspected pulmonary embolism (Group B) in whom the diagnosis was excluded by pulmonary angiography or scintigraphy. A previous history of cardiovascular disease was found in 37 patients (76%) in this group: of the 12 remaining patients, 6 were heavy smokers and 4 were significantly obese. No correlation was found between the degree of hypoxaemia and the extent of amputation of the vascular bed on pulmonary angiography or scintigraphy. Nevertheless, a pO2 of under 50 mm Hg was always associated with a severe embolism with amputation of over 40% of the pulmonary vascular bed. A significant correlation was found between the severity of hypoxaemia and the degree of cyanosis (p less than 0,05) and ECG changes (p less than 0,01). The average pO2 was 59 +/- 12 mm Hg in patients with cardiovascular disease ( n = 21) and 55 +/- 11 mm Hg with known pulmonary disease ( n = 6). A higher average pO2 was found when these conditions were absent (61,5 +/- 13 mmHg). The difference was not statistically significant unless previous cardiac and pulmonary disease were associated (pO2 = 51 +/- 14 mm Hg, p less than 0,05).

[Post-radiotherapy pericarditis. 5 cases (author's transl)]. / Péricardites post-radiques. 5 observations.

These cases represented 2.8% of the patients admitted for pericarditis during the same period. The cause of irradiation was a carcinoma of the breast in three cases and a carcinoma of the oesophagus in two cases. Acute forms of pericarditis occured 8 and 13 months after irradiations, and chronic forms after 1, 8 and 13 years. Three clinical forms were observed; two patients had an acute form; the first one with a slight effusion was easily cured, the second with cardiac tamponnade recovered after surgical evacuation, two others patients had a chronic latent effusion; after surgical evacuation, one recovered but the other one developped an occult constrictive pericarditis diagnosed by rapid volume expansion. The fifth case was a constrictive pericarditis which was effectively traited by pericardectomy. The difficulty of etiological diagnosis varies with the time and the amount of effusion. When the effusion is moderate the distinction must be made with an acute idiopathic pericarditis; when effusion is large the distinction must be made with a tuberculosis and specially a tumoral recurrence; in three cases pericardial biopsy was carried out and eliminated these diagnosises; lesions were similar: pericard was sclerous and little in cells, inflammatory signs were slight or absent. The postoperative prognosis in constrictive pericarditis may be agravated by associated myocardial lesions.

[Methyl-ergometrin maleate test during coronary arteriography in spontaneous chest pain]. / Le test au maléate de méthyl-ergométrine au cours de la coronarographie dans les douleurs thoraciques spontanées.

This coronary spasm provocation test with methyl-ergometrine maleate was carried out during coronary arteriography in 47 patients presenting with spontaneous chest pain. Coronary spasm was triggered in 16 cases, reproducing the chest pain in 11 patients, and accompanied by electrical changes in 15 cases, 12 subepicardial ischaemias and 3 subendocardial ischaemias. This test is not without danger to the patient as arrhythmias and conduction defects were recorded in 6 cases although the spasm was readily reversible on injection of intravenous glyceryl trinitrate. Of 7 patients with Prinzmetal variant angina, the test was positive 6 times, in three of which on pre existing severe organic lesions, so confirming the mechanism of this syndrome and the reliability of the test. Of 40 patients presenting with spontaneous chest pain, 10 had a positive test. In 2 of these cases the chest pain was subsequently observed with subepicardial ischaemic electrical changes, so confirming the screening value of this test. In the 7 cases where coronary spasm gave rise to electrical changes with or without pain, the logical diagnosis would appear to be spastic angina. In the 30 cases where the test was negative the subsequent outcome did not provide any proof in favour of a coronary origin of the chest pain.

[Myocardial infarct before the age of 36: 20 cases]. / L'infarctus du myocarde avant 36 ans. A propos de 20 cas.

Twenty cases of myocardial infarction in 16 males and 4 females and less than 36 are reported. The number of heavy smokers was greater than in other age groups (86%), and an association between tobacco consumption and lipid abnormalities was found in 3/4 of cases. All the females were on contraceptive treatment, one recurring during pregnancy. The clinical features of the infarctions were an onset which was usually unexpected (n=14), ar attack which was sometimes precipitated by exercise (n=3), and the infrequency of residual angina. The exercise test (n=16) showed up an associated abnormality in only one case out of four, but the fact that the rate-pressure product was normal suggests that the coronary artery networks were in a satisfactory state of function. Ventriculography (n=14) was normal in 35% of cases. Coronary arteriography (n=18) showed significant lesions in 12 cases, one trunk being affected in 6, two trunks in 5, and 3 trunks in one; the lesion index was 1.6. In 6 cases there were few changes in the coronary arteries, and the probable mechanism of the infarct is discussed: besides the possibility of a recanalised thrombus, which appears to be the likely one in two of our patients, spasm played a possible role even though the ergonovine provocation test was negative. The mortality during the first month was zero; as a secondary event over a follow-up period of 38 months, there were two deaths and four recurrences, one of which occurred in a healthy coronary vascular tree.

[Myocardial infarction following administration of oral contraceptive agents. 3 cases]. / Infarctus du myocarde après contraceptifs oraux. 3 observations

The authors report the cases of three women aged 23, 24 and 28 years, receiving oestro-progestational agents and suffering a myocardial infarction. 25 cases in the literature are reviewed. Infarction is in most cases the first symptom. The clinical picture has no special features other than the frequency of anterior localisations. Coronary arteriography carried out in 15 cases showed a lesion of one vessel in 10 patients. The most common finding was a thrombosis of the left anterior descending. The coronaries were almost of completely normal in 3 cases, diffuse lesions being found only in 2 patients. The long term prognosis, at first sight favourable since the problem is one of localised lesions, is worsened by the frequency of ventricular contraction abnomalities. Myocardial infarction in patients taking oestro-progestational agents remains rare. A logical hypothesis to explain it would be a synergistic effect between the hypercoagulability induced by the drug and the risk factors in the individual patient. They are present with a frequency similar to that seen in other series of young patients with coronary disease.