A2A adenosine receptor function in patients with vasovagal syncope.

AIMS: Adenosine is a possible mediator in vasovagal syncope (VVS) via the activation of its receptors. High expression of adenosine A2A receptors (A2AR) has been reported in VVS. The function of these over-expressed receptors in this population has never been evaluated. METHODS AND RESULTS: We used Adonis, a specific-made antibody with A2AR agonist properties, to evaluate binding parameters (i.e. dissociation constant KD) and cAMP production (i.e. EC50) by peripheral blood mononuclear cells of 16 VVS patients. Eight healthy volunteers served as controls. A2AR expression was higher in patients than controls; mean: 11.5 ± 1.2 vs. 7.7 ± 0.8 AU, P = 0.04. Also, KD values were higher in patients than controls: 2.1 ± 0.02 × 10(-7) vs. 5 ± 1 × 10(-8) M, P < 0.01 In controls, KD values were lower than EC50 (5 ± 1.7 × 10(-8) vs. 2.8 ± 0.4 10(-7) M, P < 0.01), but in patients, KD values did not differ from EC50: 2. ± 0.2 × 10(-7) vs. 2.5 ± 0.4 × 10(-7) M, P > 0.05. However, four patients had lower EC50 (3.5 ± 0.3 × 10(-8) M) than KD (2.9 ± 1.2 × 10(-7) M; KD/EC50 = 9.6), suggesting the presence of spare receptors. CONCLUSION: The function of A2AR of patients with VVS was preserved since their stimulation by Adonis led to cAMP production with an EC50 comparable with those in controls. However, their affinity was lower than those of controls. Our results suggest that A2AR are implicated in the physiopathology of VVS.

Cardiac events monitoring.

Cardiac events recorders have been developed in order to record the heart rhythm during symptoms such as palpitations or presyncope, to first make a diagnosis, and subsequently drive the treatment strategy. In other circumstances, they can be also used in asymptomatic patients (to record silent atrial fibrillation for instance). Because they are non-invasive, potentially cost-saving and relatively easy to use, the external rhythm recording devices have shown some great advances in the last years, spreading from photoplethysmographic technique to real ECG reconstruction. Technological advances in the field of microelectronics, as well as in the field of data transmission have contributed to their widespread use in cardiology. The trend for miniaturization was also expanded to the implantable recorders. This paper will review will review advantages and limitations of the different existing available well-established recording devices, as well as the last technological developments in terms of ECG recordings.

[Organization and management of acute complete atrioventricular block: Results from a Multicenter National Survey]. / Organisation et gestion aiguë du bloc atrioventriculaire complet : résultats d'une enquête multicentrique nationale.

BACKGROUND: Complete atrioventricular block (AVB3) may be an urgent potentially lifethreatening situation. Our objective was to describe the routine management of AVB 3, with emphasis on the organizational aspects. METHODS: From September 2019 to November 2019, a prospective national survey including 28 questions was electronically sent to 100 physicians (Google Form). RESULTS: The answers were collected from 93 physicians (response rate 93%). Permanent pacemaker implantation during weekends and nights (after 8PM) is possible for 49% of the operators (<5 times a year), for 15% (>5 times a year), impossible for 36% of the operators. For AVB3 nonresponsive to isoproterenol occurring during the night, a temporary pacing lead (TPL) is implanted by: the on-site medical staff on-duty (27%), the on-call interventional cardiologist (21%), the on-call electrophysiologist (19%), a permanent pacemaker is implanted by the electrophysiologist (12%), the strategy is not standardized (15%). An externalized active fixation lead (AFL) for AVB3 has already been implanted by 50% of the operators. 80 (86%) have already observed a dislocation of the TPL, a cardiac perforation already occurred in 57 (61%), a groin hematoma in 35 (38%), and this technique was proscribed for 4% of the operators. CONCLUSION: Our survey shows important disparities in terms of management of AVB3 among the different centers. An externalized AFL with a reusable generator was used by half of the centers.

[Evaluation of an "Emergency Thrombosis" care system in a university-hospital department of general emergencies]. / Évaluation de la mise en place d'une filière de soins « Urgence Thrombose ¼ dans un service hospitalo-universitaire d'Urgences générales.

GOAL: Describe the use of diagnostic, prognostic and therapeutic algorithms for venous thromboembolism (VTE), derived from the 2014 European guidelines, in a teaching hospital's emergencies department and compare two groups: the 2015 group "without a care path" and the 2017 group "with a care path". METHOD: Comparative and retrospective study of the characteristics of emergencies department patients admitted for VTE from January to June 2015 for the 2015 group and from January to June 2017 for the 2017 group. RESULTS: Seventy-nine patients were included in the 2015 group and 62 patients in the 2017 group. In 24% of cases a clinical probability rule was calculated in the 2017 group (vs. no score in 2015, P<0.05). In the 2015 group, 10% of patients did not have a D-Dimer measurement in case of low clinical probability (vs. 0% in 2017, P<0.05). For both groups, the severity score sPESI was not noted in the medical record. All patients with pulmonary embolism were hospitalized in both groups. A total of 36% of patients with deep vein thrombosis (DVT) were hospitalized in the 2015 group (vs. none in 2017, P<0.05). A total of 52.5% of patients were treated with direct oral anticoagulants (DOAS) in the 2017 group vs. 32.5% in the 2015 group (P<0.05). In 18% of cases DOAS were prescribed by emergency physicians in the 2017 group vs. 2.5% in the 2015 group (P<0.05). Mean hospital stay was 7.4 days in the 2017 group and 9.4 days in the 2015 group (P<0.05). CONCLUSION: We observed a change in clinical practices and prescriptions after the establishment of an "Emergency Thrombosis" care system. Indeed, improvement in the calculation of the clinical probability score, increase in the outpatient management of DVT, increase in prescribing DOAS and reducing the length of hospital stay were the main revisions. The implementation of standardized digitally calculated clinical and prognostic probability scores would optimize this care path, as well as allow a better distribution of the post-emergency consultations created for outpatients.

[Clinical and electrophysiological study of asymptomatic Wolff-Parkinson-White syndrome]. / Etude clinique et électrophysiologique du syndrome de Wolff-Parkinson-White asymptomatique.

AIM: This study was designed to describe clinical characteristics and electrophysiologic in patients with asymptomatic Wolff-Parkinson-White syndrome. METHODS: From December 2000 to August 2005, a total of 154 patients with accessory pathway-mediated reentry mechanism underwent electrophysiologic studies at Sainte-Marguerite and Timone hospitals in Marseille. Ninety-six patients had WPW syndrome, out of which 78 were symptomatic patients and 18 were asymptomatic. The mean age was 26 years. Sex (masculine) 17. RESULTS: The incidence of intermittent arrhythmia associated with Wolff-Parkinson-White syndrome was lower in 2 patients (11%). There was a higher occurrence of rapid induced tachycardia in 9 patients (50%). However, atrial fibrillation occurred more commonly in 6 (33%) patients. The anterograde accessory pathway effective refractory period (APRP) in patients was much shorter (less than 250 ms [N=16]) 13 patients with accessory pathways were managed by ablation. CONCLUSION: This study demonstrated the difference in the electrophysiologic characteristics of anterograde accessory pathway and the atrioventricular node in asymptomatic WPW patients, and thus concluded that radiofrequency (RF) catheter ablation is a safe and effective method to manage patients with asymptomatic WPW syndrome.

[Role of antiarrhythmic drugs in reducing the number of defibrillation shocks]. / Place des anti-arythmiques dans la réduction du nombre de chocs des défibrillateurs.

There is a logical basis for the prescription of antiarrhythmic therapy (AAT) in patients with an implanted automatic defibrillator (IAD): the prevention of supraventricular and ventricular arrhythmias, slowing the rate of a ventricular arrhythmia to improve the haemodynamic tolerance and better efficacy of anti-tachycardia stimulation. Adjuvant therapy of this kind is used in 49 to 69% of cases. Forty six per cent of patients in the MADIT I trial had AAT at the last follow-up. In the AVID trial, despite recommendations to avoid the association of AAT and [AD, 18% of patients had this combination because of the large number of shocks in 64% of cases; AAT was associated with both a reduction in the number of shocks (p < 0.05) and in the delay to a recurrence of the arrhythmia (p < 0.0001). In the CASCADE trial, carried out in survivors of cardiac arrest, the prescription of amiodarone in patients with IAD significantly reduced the number of defibrillation shocks. Finally, almost 40% of patients with IAD have an "arrhythmia storm", sometimes during follow-up, usually requiring the association of AAT. Despite the frequent association of AAT and IAD, the results of this combination have rarely been studied systematically. Only one randomised trial has been published comparing D,L-sotalol and placebo in patients with IAD. The treatment reduced the probability of a first defibrillation shock, whether appropriate or not. Amiodarone has often been proposed in association with IAD in isolated cases. The OPTIC trial (Optimal Pharmacological Therapy in Implantable Cardioverter), currently under way, has three sub-groups of IAD (betablocker, amiodarone and betablocker, sotalol), with the aim of determining the preventive value of each AAT with respect to the IAD performance. In addition to the results of combined treatment, the interaction with the threshold of defibrillation is an important factor which is not clearly understood at present. Class I AAT increases the threshold of defibrillation whereas Sotalol reduced it. Amiodarone has a variable effect, neutral or deleterious. The OPTIC trial should provide valuable information via the sub-analysis of the effects of drugs on the threshold of defibrillation in each of the three arms of the trial.

[Pacemaker longevity. Replacement of the device]. / Longévité des stimulateurs cardiaques. Remplacement du boîtier de stimulateur.

Life expectancy of patients implanted with cardiac pacemakers has largely increased, so that generator replacement is becoming an important part of the activity in most of the implanting centers. In more than 70% of the cases, the indication for pacemaker replacement is normal battery depletion. Since the new devices are more and more sophisticated and smaller, longevity optimization becomes a real challenge. The main determinant of pacemaker longevity is the output programmed for the pulse generator. It mainly depends on the output voltage and duration settings. The pacing impedance and the percentage of time with pacing are other major determinants of pacemaker longevity. Each manufacturer provides specific policy but the battery voltage and internal impedance are the more accurate and easy-to-obtain battery depletion parameters. The magnet rate is still frequently used but is less valuable since it can drop abruptly at the end of battery life. The complication rate of pacemaker replacement is three-fold higher than the one of first implant. Infections, skin erosions and lead related complications are not uncommon. The replacement should be systematically preceded by the checking of several points including the patient's pacemaker dependency, the necessity to replace or extract one or several leads, the venous system status, the compatibility between the new generator and the leads and the necessity to upgrade the pacing system or to change the pacemaker pocket.

Prolonged QT interval and altered QT/RR relation early after radiofrequency ablation of the atrioventricular junction.

This study evaluated the paced QT interval in the days after radiofrequency ablation of the atrioventricular junction in patients with chronic rapid atrial fibrillation. There is an abnormality in the dynamics of the paced QT interval until the second day after ablation, resulting in an increased duration when the paced heart rate is <75 beats/min.

The effects of antimalarial drugs on ventricular repolarization.

Cardiotoxicity has become a major concern during treatment with antimalarial drugs. Lengthening of the QTc and severe cardiac arrhythmia have been observed, particularly after treatment with halofantrine for chloroquine-resistant Plasmodium falciparum malaria. The purpose of this prospective study was to evaluate whether antimalarial agents alter dispersion of the QTc and ventricular repolarization dynamicity. Sixty patients with uncomplicated falciparum malaria were randomly allocated in four groups of 15 patients and treated with quinine, mefloquine, artemether, or halofantrine at recommended doses. Patients in treatment groups were compared with a group including 15 healthy controls with no history of malaria and/or febrile illness within the last month. QTc dispersion was measured on surface electrocardiograms. Repolarization dynamicity was analyzed from Holter recordings, which allow automatic beat-to-beat measurement of QT and RR intervals. Plasma drug concentration was determined by reversed-phase high-performance liquid chromatography. No change in QTc dispersion was observed after treatment with quinine, mefloquine, or artemether. Treatment with halofantrine was followed by a significant increase in QTc dispersion at 9 hours (P < 0.0001) and 24 hours (P < 0.01). Assessment of QT heart rate variability by QT/RR nychtohemeral regression slope demonstrated no significant difference between the artemether (mean +/- SEM = 0.170 +/- 0.048), mefloquine (0.145 +/- 0.044), and the control groups (0.172 +/- 0.039). A significant decrease in the Q-eT/RR slope was observed in the quinine group compared with the control and artemether groups (0.135 +/- 0.057; P < 0.04). With halofantrine, a significant increase in the QT/RR regression slope (0.289 +/- 0.118) was observed (P < 0.0002). QTc interval, QT dispersion, and QT regression slope were significantly correlated with halofantrine and quinine plasma concentration. Mefloquine and artemether did not alter ventricular repolarization. Quinine induced a significant decrease in QT/RR slope of the same order of magnitude as those previously observed with quinidine. Both QTc dispersion and QT/RR slope were significantly modified by halofantrine. These repolarization changes were related to a class-III antiarrhythmic drug effect and may explain the occurrence of ventricular arrhythmia and/or sudden deaths reported after halofantrine intake.

Right- and left-sided interatrial septal aneurysm mimicking atrial tumor and stroke.

We report the cases of two patients with cerebral embolization and interatrial septal aneurysm. Transesophageal echocardiography required for stroke showed right-sided interatrial septal aneurysm in the first patient and left-sided interatrial septal aneurysm in the second. In the two patients, interatrial septal aneurysm was mimicking atrial cystic tumor or abscess. Significant internal carotid artery stenosis was found in the first patient and aortic arch atheroma with mobile components but no patent foramen ovale in the second patient. In the two patients, interatrial septal aneurysm appears to be only an incidental finding and not the true cause of stroke. Furthermore, we discuss the differential diagnoses of atrial masses.

Clinical electrophysiologic effects of a single high oral dose of amiodarone.

Several recent reports have described the antiarrhythmic effects of a single high oral dose of amiodarone but clinical electrophysiologic effects have not been reported. The present study was performed to assess electrophysiologic effects in 12 patients. After baseline electrophysiologic studies (EPS) patients were administered a single oral dose of 30 mg/kg of amiodarone. EPS was repeated 7.5 +/- 0.5 hours later. Plasma levels of amiodarone and its metabolite desethylamiodarone were determined at the time of the second EPS, Holter monitoring was performed for 24 hours after amiodarone administration. Amiodarone significantly increased the following parameters: corrected QT interval (+4.5%), functional refractory period of the right atrium (+7%); AH interval (+12.3%), effective refractory period of the atrioventricular node (+18.5%), and cycle length of Wenckebach block (+8.4%). These effects were not correlated with plasma levels of amiodarone and desethylamiodarone. Holter monitoring detected no significant bradycardia or arrhythmia. These findings indicate that the effects of a single high oral dose of amiodarone are the same as those known to be induced by acute intravenous administration.

[Left bundle branch block. Electrocardiographic and prognostic aspects]. / Bloc de branche gauche. Aspects électrocardiographiques et pronostiques.

The concept of left bundle branch block (LBBB) was recognised at the beginning of the 20th century but confusion, due to the extrapolation data from animal experimentation, persisted for many years between the electrocardiographic appearances of LBBB and right bundle branch block (RBBB). The typical appearances of LBBB are now well known and consist of: 1) increased duration of the QRS complex > 0.12 seconds; 2) a wide, exclusive R wave with a plateau or notched summit in the left precordial leads and usually in D1 and aVL; 3) an important delay in the intrinsecoid deflection in the left precordial leads (0.08 to 0.12 seconds after the onset of QRS); 4) an axis of repolarisation opposite that of the QRS complex with so-called "secondary" abnormalities. The authors emphasise that some electrocardiographic variants carry a poor prognosis, in particular those with major QRS axis deviation to the left or, much less commonly, to the right. The diagnosis of left ventricular hypertrophy is possible in cases of LBBB by using the criteria of QRS amplitude in the left precordial leads. On the other hand, the diagnosis of myocardial infarction is more difficult, the criteria being very specific but having a sensitivity < 50%. The deleterious effects of LBBB on the haemodynamics are well known but their study has become a new firld of research since the introduction of bi-ventricular pacing for the treatment of cardiac failure. In dilated cardiomyopathy, LBBB increases the duration of functional mitral regurgitation and decreases left ventricular filling times. The prognostic implications of LBBB have been the object of many studies: the reports in the literature indicate a large increase in mortality when LBBB develops in patients over 44 years of age. The progression to complete atrioventricular block is common only when the HV interval exceeds 100 ms. In other cases, the prophylactic implantation of a cardiac pacemaker does not improve the prognosis which depends on the severity of the underlying cardiac disease.

[The best of cardiac pacing in 1999]. / L'essentiel de 1999 en stimulation cardiaque.

Since the first clinical application to man forty years ago, for the treatment of bradycardia, cardiac pacing has been the object of continuous technological innovation in parallel with those in electronics and computerisation. However, independently of these expected advances, there has been a surprising widening of the field of application of pacing into those of haemodynamics and rhythmology. The recent publication of the long-term results of the Pacing in Cardiomyopathy (PIC) study confirmed the sustained decrease of intraventricular pressure gradient, of NYHA functional stage and improved quality of life of patients with hypertrophic obstructive cardiomyopathy paced in the DDD mode. The investigators also underlined the placebo effect of the pacemaker. The decrease in risk of sudden death and the reduction in ventricular remodelling have not been demonstrated yet. More recently, biventricular pacing has been proposed for the treatment of dilated cardiomyopathy and a French study showed a long-term improvement in NYHA stage and effort capacity. Several prospective randomised trials are under way to validate this indication. Acute haemodynamic evaluations have confirmed the efficacy of biventricular stimulation but also underline the value of left ventricular pacing alone. The effects on mortality, the selection of patients and the optimal configuration of pacing remain to be defined. In the field of prevention of atrial arrhythmias, the results of the multicenter SYNBIAPACE study, investigating biatrial pacing in patients with interatrial conduction defects, only showed a tendency to an increase in the delay before recurrence of atrial fibrillation. The value of the memory functions of pacemakers and the algorithms of prevention of atrial arrhythmias are still under investigation. Haemodynamic transducers have been introduced in some recent pacemakers to assess myocardial contractility and have applications in the evaluation of different pacing modes and in the optimisation of the atrioventricular interval. Their value in the treatment of neurocardiogenic syncope is under evaluation. In conclusion, it is not overoptimistic to imagine that, in the near future, the cardiac pacemaker will be part of a "control and treatment system" well over the limits of treating patients with bradycardia.

[Implantable defibrillator and ventricular resynchronisation]. / Défibrillateur implantable et resynchronisation ventriculaire.

Ventricular resynchronisation by pacing, introduced at the end of the 1990s, has revolutionised the management of advanced chronic cardiac failure. Its value in the reduction of haemodynamic mortality has been demonstrated in the latest studies. However, despite these decisive advances, patients with cardiac failure continue to have a high incidence of sudden death which, classically, according to its stage of progression, represents 28 to 68% of deaths in this condition. The implantable automatic defibrillator (IAD) has been shown to be effective in preventing sudden death, mainly in patients with severe left ventricular dysfunction. Based on these data, and in a context of rapid technological progress, devices capable of both defibrillating and resylchronising the heart have been introduced. The problems experienced at the beginning of their utilisation, mainly related to "double-counting" of left and right ventricular electrical activation have been resolved and the method is now technically feasible. A complication rate >10%, mainly due to the implantation of the left heart catheter, continues to bear witness to the difficulties of this technique and to the severity of the condition of patients referred for the treatment. The COMPANION trial has shown a greater reduction in mortality of patients treated by resynchronisation associated with IAD compared with resynchronisation alone or medical therapy in > or = Stage III cardiac failure. The SCD-HeFT trial has recently demonstrated that the primary prevention of global mortality by the IAD is effective in cardiac failure irrespective of the underlying cardiac pathology, especially in functional Stage II. These results should lead to significant increase in the indications for implantation of devices capable of both resynchronisation and defibrillation. However, the obvious problems of cost associated with the difficulty of the technique mean that a systematic attitude cannot be recommended. A case-by-case discussion has its place but the causal cardiac disease, ischaemic or not, does not seem to be a determining factor.

[The best of arrhythmias in 2002]. / L'essentiel de 2002 en rythmologie.

In the era of evidence based medicine the year 2002 will be remembered principally for having brought the results of two large trials in areas of daily preoccupation for rhythmologists: those of atrial fibrillation and of prevention of rhythmic sudden death. The Atrial Fibrillation Following Investigation of Rhythm Management (AFFIRM) study compared strategies for controlling frequency and rhythm in atrial fibrillation for subjects aged over 65 years or having at least one risk factor for cerebral vascular accident. In an unexpected fashion, although in accordance with other recent results, the two strategies are equivalent in terms of mortality. It also underlined the necessity of continuing anticoagulation with an INR > 2. even when it is proposed to maintain the rhythm. In the matter of primary prevention of sudden coronary death, the Multicenter Automatic Defibrillator Implantation Trial II (MADIT II) had the originality of evaluating patients with no other risk factor than a severe alteration in left ventricular ejection fraction (30% Pounds). This "simple" selection of patients at risk allowed a mortality reduction of 30% to be demonstrated by the placement of a ventricular defibrillator, in addition to that brought about by optimal conventional treatment. In the chapter on syncope, the Framingham study delivers information in terms of incidence and long term prognosis, in a non selected population. Even if these results are difficult to compare with those recent studies using notably the inclination test, they remind us of the poor prognosis of cardiac origin syncope and the absence of excess mortality in patients affected by vagal syncope. The significance of these very wide series does not preclude drawing the greatest attention to the work by the Bordeaux team who have been able to provide evidence, in 27 patients with relapsing idiopathic ventricular fibrillation, of the initiator role of extra-systoles originating from the distal Purkinje network. A medium term cure was obtainable by ablation of these extra-systoles. This work of course allows the prospect of application to other types of malign ventricular arrhythmias.

[Protection systems of dual-chamber pacemakers against atrial arrhythmia]. / Les systèmes de protection des stimulateurs double chambre contre les arythmies atriales.

The incidence of atrial arrhythmias may be as high as 10% in patients paced in the DDD mode carrying the risk of tracking of rapid atrial rates leading to non-physiological rapid ventricular paced responses. The unquestioned benefits of DDD pacing in terms of mortality and morbidity has led to the conservation of this mode in such situations, but with various systems of protection. Initially, limitation of the maximum frequency and programming a long atrial refractory period were proposed, but these measures were contrary to the physiological vocation of DDD pacing. Similarly, DDI and DDIR pacing, which do not ensure synchronisation on spontaneous P waves, were suggested, but in some cases there was loss of atrio-ventricular synchronism in sinus rhythm. Therefore, the manufactures developed "fallback systems" allowing programming of physiological pacing in patients with paroxysmal atrial arrhythmias. The aims of these systems are: 1) to detect atrial arrhythmias; 2) to change the pacing mode when the arrhythmias is detected for ventricular pacing not synchronised on the P wave (VVIR or DDIR modes); 3) to revert to the initial mode of pacing when the arrhythmia is over. This paper describes the different specialised algorhythms currently available, with their advantages and draw-backs, their main indications and possible future developments.

[A rare cause of inappropriate shocks of an implantable automatic defibrillator. Twiddler syndrome]. / Une cause rare de chocs inappropriés d'un défibrillateur automatique implantable. Le Twiddler's syndrome.

The authors report the case of a patient with an automatic defibrillator implanted by an endocavitary approach. The device emitted a series of inappropriate shocks. They were triggered by the detection of myopotentials resulting from lesions of the lead due to Twiddler's syndrome. This was reproduced by telemetry in real time and confirmed by chest and abdominal X-ray and the peroperative findings. Treatment consisted of ablation of all implanted material which was replaced by a new retropectoral model.

[Hospital management of atrial fibrillation. Epidemiologic data and therapeutic strategy. Report of 100 consecutive patients]. / Prise en charge hospitalière de la fibrillation auriculaire. Données épidémiologiques et stratégie thérapeutique. A propos de 100 patients consécutifs.

Despite recent large scale trials, the management of atrial fibrillation remains very variable. The authors report the results of a prospective study of the management of atrial fibrillation in their department. One hundred consecutive patients admitted for atrial fibrillation were included in the study. The epidemiological and clinical data and the results of the therapeutic strategy were recorded prospectively. Three embolic complications occurred before hospital admission. The hospital stay was marked by spontaneous reduction of atrial fibrillation in 14 cases in the 6 hours following admission. The therapeutic strategy was the following: 40 arrhythmias were respected (well tolerated, > 1 year or with a left atrium 60 mm). Oral amiodarone (30 mg/Kg and 15 mg/Kg the next day) was given to 22 patients. Only 9 patients (41%) were converted (average delay of 12 hours). Four patients received intravenous amiodarone, reducing two arrhythmias. Twenty patients were treated by external electrical cardioversion of first intent and 14 after failure of pharmacological reduction. All of these procedures, early (after 48 hours anticoagulation and transoesophageal echocardiography), or late (after 1 month of anticoagulation), restored sinus rhythm without complications, especially embolic. This register showed a relatively low efficacy of oral amiodarone in the reduction of atrial fibrillation and underlines the efficacy and safety of external electrical cardioversion, even when performed early.

[Myocardial infarction after 80 years of age. Apropos of 157 cases]. / L'infarctus du myocarde après 80 ans. A propos de 157 cas.

The authors evaluated the features of myocardial infarctions in a population of 157 subjects aged 80 years or more out of a total of 1,610 patients admitted for myocardial infarction. It was a common condition in this age group (9.8% of the population) with a female predominance (61.8%), the main risk factor begin hypertension. A previous history of angina or infarctions, silent ischaemia, atypical electrocardiographic forms and anterior infarction were significantly more common. The outcome was characterised by a higher prevalence of haemodynamic complications with cardiac failure in 60% of cases and cardiogenic shock in 10% of cases. Atrial fibrillation was also more common though severe ventricular arrythmias were more infrequent. From the therapeutic point of view, 95.7% of octogenarians were given intravenous heparin but thrombolysis was undertaken in only one case. Coronary angiography, angioplasty and cardiac surgery were exceptional. Hospital mortality was 26.7%, seven times higher than that observed in patients under 65 years of age and nearly twice that of patients 65 to 79 years of age. After hospital admission, 45% of octogenarians were prescribed a calcium inhibitor, 37.2% a platelet anti-aggregant agent, 17.2% long-term oral anticoagulants and 1.9% a betablocker. These results show that myocardial infarction after 80 years of age is common, serious, but treated conventionally.