[Differences between management guidelines and global health strategies for arterial hypertension with metabolic disorders in France in 1999. Ohara study]. / Différences entre recommandations de prise en charge et stratégie globale médicale dans l'hypertension artérielle avec désordres métaboliques en France en 1999. Etude Ohara.

Taking into account all the risk factors and blood pressure levels, as indicated by several American and European recommendations available since 1997, is a leading strategy to reduce mortality and morbidity of hypertensive patients. The aim of this study was to quantify how, in 1999. French practitioners applied recommendations on hypertension (HTN), diabetes and hypercholesterolemia in recently diagnosed hypertensive patients and to evaluate whether or not the recommended targets were met. 1639 French GPs and cardiologists included 5831 recently diagnosed (7.5 +/- 3.6 months) hypertensives (57 +/- 12 years of age, M/F = 55/45%). Initial BP was 173 +/- 15/99 +/- 9 mmHg. 56% had no concomitant disease, 36% had either diabetes, dyslipidemia or coronary heart disease, 8% had at least two concomitant diseases. At the time of the study corresponding to 6.3 +/- 3.8 months after initiation of diet and/or medical treatment, their BP was 148 +/- 17/86 +/- 11 mmHg (-25/-19 mmHg). At that time only 37% of patients with stage 2 HTN were encouraged to adopt lifestyle modifications without any medical treatment as recommended by the JNC VI. Among these hypertensives, measurement of plasma cholesterol was performed in only 61%, HDL-C/LDL-C in 26% and blood glucose in 51%. In the patients with dyslipidemia, LDL-C was measured in only 47%. In the 677 diabetic patients only 27% had a glycated hemoglobin measurement. The percentage of patients reaching target BP was 59% as regard DBP < 90 mmHg, 25% as regard SBP < 140 mmHg, and 23% reached both target values of BP. In addition, 30% of patients with dyslipidemia reached the target LDL-C as defined by French recommendations (ANAES 1996) and 30% of the diabetic patients reached the target value for glycemia recommended by ADA (1997). In 1999 in France, a minority of patients reaches the national or international recommended target values for blood pressure, glycemia and plasma LDL-cholesterol. In spite of that, French practitioners do not implement all the available diagnostic tools to improve the treatment of metabolic disorders in hypertensive patients. As a conclusion, to improve the prognosis of hypertensive patients, it is mandatory to raise the awareness of physicians about multiple risk factor management and help them implement the recommendations in their daily practice.

Acute hemodynamic effects of amlodipine 15 days after a myocardial infarction in normotensive patients treated with atenolol.

The acute hemodynamic effects of 20 mg iv amlodipine were evaluated in a placebo-controlled study in 16 normotensive patients 15 +/- 1 days after an acute myocardial infarction by covariance analysis. Atenolol was given orally for at least 1 week before the study to maintain the heart rate between 50 and 60 beats/min. All patients were given two doses of 10 mg of amlodipine, or 10 ml of a placebo twice, in i.v. infusion lasting 2 minutes each. Hemodynamic data were collected during the control period and 15 minutes after each of the two amlodipine or placebo infusions. At the time of the last measurements, 15 minutes after the second amlodipine or placebo infusion, the plasma amlodipine level was 31 +/- 16 micrograms/l and the plasma atenolol level was 773 +/- 564 mu/l in the amlodipine group versus 795 +/- 916 micrograms/l in the placebo group. There were no chronotropic, dromotropic, or inotropic effects. The main hemodynamic effect was a fall in systemic vascular resistance (1548 +/- 591 dynes.sec.cm-5 to 1176 +/- 526 dynes.sec.cm-5, p = 0.045) with decreases in aortic pressure and in the left ventricular stroke work index. The left ventricular ejection fraction was 51 +/- 12% in the placebo group and 56 +/- 15% in the amlodipine group (ns) during the control period, and did not change after infusion of placebo or amlodipine. Left ventricular compliance seemed to be enhanced by amlodipine, because the end-diastolic left ventricular volume index rose from 82 +/- 11 ml/m2 to 87 +/- 11 ml/m2 (p = 0.026) 15 minutes after the beginning of the second infusion of 10 mg of amlodipine, without any change in end-diastolic left ventricular pressure. Intravenous infusion of 20 mg of amlodipine is well tolerated 15 days after acute myocardial infarction in normotensive patients without deeply depressed left ventricular systolic function and chronically treated with atenolol. The main hemodynamic effects observed are potentially useful for such patients.

[Myocardial infarction with normal coronary angiography. Apropos of 9 cases. A retrospective and comparative study]. / Infarctus du myocarde à coronaires angiographiquement normales. A propos de 9 cas. Etude rétrospective et comparative.

This retrospective study was designed to determine the characteristics of myocardial infarction with normal coronary arteries. The files of consecutive patients admitted to hospital for a first infarction in 1992 and 1993 were analysed. Patients younger than 70 years of age, who had undergone coronary angiography during their admission to hospital were selected. A total of 109 infarctions complied with these criteria and 9 of them were associated with angiographically normal coronary arteries. In this series, patients with angiographically normal coronaries tended to be younger than those with at least one stenotic coronary artery (47 +/- 13 years vs 55 +/- 11 years, p = 0.07). The sex ratio did not differ between the two groups. The body mass index of patients with normal coronary arteries was significantly lower (22.9 +/- 3.9 kg/m2 vs 26.3 +/- 3 kg/m2; p = 0.02). These patients more frequently reported a history of phlebitis (3/9 kg/cm2 vs 26.3 +/- 3 kg/cm2; p = 0.02). These patients more frequently reported a history of phlebitis (3/9 vs 2/100). The frequency of anterior and posterior infarctions was virtually the same. Myocardial infarction with normal coronary arteries appears to be less severe, as reflected by the creatine phosphokinase peak (867 +/- 268 IU/l vs 1921 +/- 1389 IU/l), the maximal sum of ST elevation (5 mm vs 16 +/- 12 mm; p = 0.05), the percentage of left ventricular akinesia on angiography (25.5 +/- 4 vs 38.7 +/- 11.8; p = 0.01), and the lower ventricular end-diastolic pressure (11.5 +/- 3.5 mmHg vs 38.7 +/- 11.8 mmHg; p = 0.02). Fewer complications were observed during the acute phase, with no deaths. During the subsequent follow-up, with a median of 2 years, no recurrent infarctions, no cardiac decompensation and no deaths were observed in the group with normal coronary arteries. Two patients presented an episode of angina and one developed a recurrent episode of phlebitis. In the other group of 100 patients, 12 deaths were observed during the acute period, followed subsequently by 2 other deaths, 10 episodes of recurrent angina, 2 recurrent infarctions and 12% of patients developed heart failure. In this series, infarction with normal coronary arteries therefore appears to have a good prognosis, possibly because of more limited myocardial necrosis. No abnormalities of haemostasis or coagulation were observed in these patients.

High flow coronary fistula closure by percutaneous coil packing.

Few cases of transcatheter coronary fistula closure have been reported. High flow coronary fistulae are usually treated by surgery. This case report presents a 5.4 liters/min flow coronary fistula percutaneously closed by steel coils. This large flow needed the packing of 25 coils, 10-15 cm long, for its total occlusion.

Predictive value of the P wave at implantation for atrial fibrillation after VVI pacemaker implantation.

This study assesses the value of P wave measurements on the surface ECG at implantation, in the prediction of atrial fibrillation in VVI paced patients. From a consecutive series of 320 pacemaker implantations 172 VVI paced patients for symptomatic atrioventricular block (AVB) (n = 126; mean age 69 +/- 14) or sick sinus syndrome (SSS) (n = 56; mean age 68.6 +/- 12) and in sinus rhythm at implantation were used in this study. P wave duration in V1 is correlated with the incidence of atrial fibrillation during 5 years of follow-up. V1 at implantation was significantly longer (114.6 +/- 2.7 msec) in the patients who developed atrial fibrillation than in those who did not (91.9 +/- 2.7 msec) (P < 0.001). Although positive predictive accuracy increases progressively for higher V1 values for AVB and SSS, the negative predictive and diagnostic accuracy of V1 criteria were less in SSS. Application of the Bayes' theorem showed that in SSS the probability to develop atrial fibrillation is 33% for V1 < 110 msec and is for V1 < 90 msec still higher than that reported in DDD paced patients. In the AVB group the probability to develop atrial fibrillation is 8% for V1 < 110 msec and 6% for V1 < 100 msec. It seems, therefore, that atrial stimulation (AAI or DDD) is always indicated in SSS. In AVB with V1 < 100 msec, DDD pacing, if not needed for other indications, apparently does not offer much benefit in the prophylaxis of atrial fibrillation.

[P wave changes and atrial fibrillation after implantation of VVI type pacemaker]. / Modifications de l'onde P et fibrillation auriculaire après l'implantation d'un pacemaker type VVI.

The P waves of patients with VVI pacemakers were compared with those of DDD pacemakers at implantation and then regularly for 5 years. A certain number of cardiac pathologies are known to cause P wave changes. The incidence of atrial fibrillation (AF) was much higher in VVI than in DDD patients. In the VVI group, the incidence was much greater in patients paced for sinus node disease than in patients paced for AVB. Analysis of sinus P wave characteristics in 320 patients with VVI pacemakers shows progressive abnormalities of atrial function with time. The expression of this atrial dysfunction is a statistically significant prolongation of the P wave in V1 and dII and of the terminal part of the P wave in V1. The factors responsible for this abnormality and which favours the occurrence of AF are quasi-permanent pacing, the presence of retrograde conduction and an abnormality of atrial activation at the time of implantation.

[Does amiodarone have a benefit effect on mortality?]. / L'amiodarone a-t-elle un effet bénéfique sur la mortalité?

Amiodarone, an anti-ischaemic and anti-arrhythmic drug, has been the object of numerous studies and seems to be highly effective in the treatment of severe ventricular arrhythmias on dilated cardiomyopathies, as well as of hypertrophic or ischaemic heart diseases. Some studies have shown a decrease in the incidence of sudden death in patients under amiodarone, but most of these studies were conducted on limited series with an insufficiently strict methodology. Contrary to other antiarrhythmic agents, amiodarone seems to be devoid of significant proarrhythmic effect and of depressant effect on cardiac function. Its anti-ischaemic activity has been demonstrated in exercise-induced and spastic angina. The side-effects of amiodarone are mainly extracardiac, and they may be a source of concern when they produce dysthyroidism or pulmonary pathology; however, they can be detected, or even prevented, by careful monitoring. Owing to its mechanism of action and its potential effectiveness, amiodarone deserves to be studied in patients at high risk of sudden death, especially those who suffer from severe ventricular arrhythmia on ischaemic cardiopathy with or without ventricular dysfunction. Three extensive clinical trials have been devised to determine with accuracy the effect of amiodarone on the mortality of patients who have survived a myocardial infarction or present with heart failure. At the end of these trials, it will perhaps be possible to evaluate the influence of a long-term amiodarone treatment on the mortality of patients whose life expectancy is shortened. The results obtained will be weighed against the side-effects of the treatment to obtain a benefit/risk ratio which, for the time being, is imperfectly known.

[Influence of preload changes on the filling function of the left heart ventricle studied by Doppler echocardiography]. / Influence des variations de la précharge sur la fonction de remplissage du ventricule gauche étudiée par écho-doppler.

Left ventricular filling may be studied non-invasively by Doppler echocardiographic recording of transmitral blood flow. This study reports the variations in this flow induced by changing cardiac preload by administering trinitrin or by vascular filling in 27 patients undergoing catheterisation. Left ventricular end diastolic pressure (LVEDP) was measured by the pig-tail catheter used for ventriculography. Transmitral flow was recorded by pulsed Doppler using the apical view. The parameters studied were those of the early diastolic E wave and the end diastolic A wave. The hemodynamic and echocardiographic measurements were performed under basal conditions, after trinitrin and after vascular filling. Trinitrin was given to 14 patients and led to a fall in LVEDP from 17.6 +/- 4.5 to 6.7 +/- 1.4 mmHg (p less than 0.001). The amplitude of the mitral E wave decreased and the E/A ratio fell from 0.93 +/- 0.37 to 0.71 +/- 0.32 (p less than 0.001). Thirteen patients underwent vascular filling which increased LVEDP from 10.9 +/- 5 to 27 +/- 4 mmHg (p less than 0.001). The mitral E wave increased and the E/A ratio rose from 0.96 +/- 0.32 to 1.27 +/- 0.23 (p less than 0.01). The patients received trinitrin and then underwent vascular filling. The LVEDP decreased from 16 +/- 3.9 to 8 +/- 2.9 mmHg (p less than 0.001) and then rose to 28.3 +/- 3.5 mmHg (p less than 0.001). The E/A ratio fell after trinitrin from 0.91 +/- 0.40 to 0.58 +/- 0.30 (p less than 0.01) and then rose to 1.42 +/- 0.60 (p less than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

Evolution of P wave characteristics after pacemaker implantation.

This study is an investigation of the long-term effects of VVI pacing on the atrium as derived from the evolution of P wave characteristics of 285 patients. The occurrence of left and right atrial disease is demonstrated as well as the evolution of left atrial hypertrophy in some cases. A comparison is made with DDD pacing and special attention is given to the progression to atrial fibrillation.

Kinetics and hemodynamic effects of intravenous nicardipine modified by previous propranolol oral treatment.

Intravenous nicardipine, 5 mg, was administered in two comparable groups of eight patients with chronic coronary artery disease but no clinical signs of heart failure. One group had received no previous treatment and served as a control group, and the other had received long-term treatment with large oral doses of propranolol. Blood concentrations of nicardipine were higher, and the area under the plasma concentration curve was greater in the group previously treated by propranolol. The total clearance of nicardipine was decreased in patients taking propranolol, without a change in the half-life of the drug. Typical hemodynamic responses, namely, a decrease in aortic pressure and in arterial resistances, were greater and more lasting in patients previously treated orally by propranolol. Filling pressure remained stable in both groups. The nicardipine infusion did not induce signs of dromotropic or inotropic negative effects in either group. The greater and more lasting hemodynamic effects of nicardipine in the group previously treated orally by propranolol do not seem to be related to an overall hemodynamic action of propranolol, but are probably due to higher nicardipine plasma levels, and may be caused by a decrease in hepatic blood flow induced by propranolol, with a consequent decrease in nicardipine clearance and by a smaller nicardipine volume of distribution in the propranolol group.

Obstructive calcification of the thoracic aorta revealed by dilated cardiomyopathy.

Obstructive calcification of the thoracic aorta appears as acquired coarctation of the aorta. The case we present is of note because it presented as a dilated cardiomyopathy. The diagnosis, suspected on chest X-ray, was confirmed by catheterization, aortic angiography and thoracic computer tomography. The patient underwent aortic endarterectomy, but died in the post-operative period. Review of the literature shows that the pathogenesis of the condition remains unclear.

[Bepridil and bundle of His block. Apropos of a case]. / Bépridil et bloc intrahisien. A propos d'un cas.

The first case of atrioventricular block located in His bundle observed during oral treatment with bepridil is reported; the block subsided when the drug was discontinued and reappeared when it was reintroduced. Electrophysiological studies performed with bepridil have shown that, as could be foreseen from its beneficial or undesirable effects, this calcium antagonist has some properties of Vaughan Williams' class I antiarrhythmic agents and alters subnodal conduction. Clinical studies indicate that in therapeutic doses this alteration has little or no significance, but it may reach clinical expression when latent of patient pre-existing disorders of conduction within or below His bundle are present.

Aortic percutaneous transluminal valvuloplasty in elderly patients by balloon larger than aortic anulus.

Twenty-four elderly patients (79 +/- 7 years) with long-standing calcified aortic stenosis have been divided in two comparable groups of 12. The first group was treated with 19 mm balloon percutaneous transluminal valvuloplasty, where the balloon diameter was always smaller than the aortic anulus diameter. Peak-to-peak aortic valve gradient decreased from 76 +/- 32 mmHg to 30 +/- 19 (P less than .05), and the aortic valve area, calculated by Gorlin formula, increased from 0.40 +/- 0.17 cm2 to 0.57 +/- 0.17 (P less than .05). The second group was treated with a trefoil 25 mm balloon, always larger than the aortic anulus diameter. In this second group, peak-to-peak aortic valve gradient decreased from 73 +/- 34 mmHg to 23 +/- 15 (P less than .05), and aortic valve area increased from 0.47 +/- 0.14 cm2 to 0.88 +/- 0.36 (P less than .05), increasing thus more than in group I (P less than .05). Clinical tolerance to balloon inflation was not the same according to individual patients but was similar between the two groups; complications were comparable in the two groups. These results suggest that aortic valvuloplasty by trefoil balloon larger than aortic anulus can provide wider aortic valve area without increasing complication rate.

[Myocardial infarction in Behçet's disease]. / Infarctus du myocarde au cours de la maladie de Behçet.

A case of myocardial infarction in a 23-year old male patient with Behçet's disease is reported. The infarction occurred 4 years after the onset of the disease, which had been marked by recurrent venous thrombosis. Coronary arteriography showed stenosis of the anterior interventricular artery and occlusion of the first diagonal artery; the other coronary vessels were normal. A search for vascular risk factors, including haemostasis, was undertaken, yielding only moderate cigarette-smoking. About 10 cases of myocardial infarction associated with Behçet's disease have been reported. They concerned young, usually male subjects. Infarction usually occurred late in the course of the disease, and vascular risk factors were seldom elicited. The leukocytoclastic vasculitis of Behçet's disease alone may be responsible for stenosis, thrombosis and false arterial aneurysms, as shown by anatomical studies. The physiopathological mechanisms involved (reduction of endothelial or systemic fibrinolytic activity, rise in fibrinogen and factor VIII) are still unclear; we believe that these abnormalities are inconstant. Behçet's disease may be regarded as a possible cause of myocardial infarction in young subjects.