Is the gap between guidelines and clinical practice in heart failure treatment being filled? Insights from the IMPACT RECO survey.

BACKGROUND: Recent registries have shown that recommended drugs for the treatment of chronic heart failure (CHF) are under-prescribed in daily practice. AIMS: To determine prescription rates of CHF drugs, and to assess predictive factors for drug prescription using data from a large panel of French cardiologists. METHODS AND RESULTS: We included 1919 outpatients, with NYHA class II-IV heart failure and a left ventricular ejection fraction <40%. The most frequently prescribed drugs were diuretics (83%), angiotensin converting enzyme inhibitors (ACE-I) (71%), beta-blockers (65%), spironolactone (35%) and angiotensin receptor blockers (ARB) (21%); 61% of patients received a combination of a beta-blocker and an ACE-I or ARB. Target doses were reached in 49% of the patients for ACE-I, but in only 18% for beta-blockers and in 9% for ARBs. Multivariate analyses showed that age >75 years was an independent factor associated with under-prescription of ACE-I-ARBs, beta-blockers or spironolactone. Renal failure was associated with a lower prescription of ACE-I-ARB and spironolactone, and asthma was a predictor of under-prescription of beta-blockers. CONCLUSIONS: In this contemporary survey, prescription rates of CHF drugs were higher than previously reported. However, dosages were lower than those recommended in guidelines. Age remained an independent predictor of under-prescription of CHF drugs.

[Flecainide by the intravenous route: a new method for decreasing auricular fibrillation]. / Le flécaïnide par voie intraveineuse: une nouvelle méthode de réduction de la fibrillation auriculaire.

The action of intravenous flecainide was studied in patients presenting a tachyarrhythmia secondary to a permanent atrial fibrillation of recent onset. We obtained 9 improvements in 15 patients included in the protocol which consisted in the intravenous injection of 2 mg/kg of flecainide in 10 minutes. The side effects were minimal: no sign of cardia insufficiency nor alteration of the arterial blood pressure was noted. Nevertheless, although interesting, this method to decrease atrial fibrillation is not, in our opinion, destined to replace external electrical shock, except in some special cases.

[Agranulocytosis caused by captopril]. / Agranulocytose au captopril.

Captopril, an inhibitor of the conversion enzyme, is a medication with a known efficacy in the treatment of arterial hypertension and congestive cardiac insufficiency. Its side-effects are few. Among them, agranulocytosis is a severe complication, all the more severe and frequent as it occurs in patients with chronic renal insufficiency, collagen disease, or patient treated with medication having a leucopenic potential. Our case reports an agranulocytosis secondary to captopril in a patient with cardiac insufficiency presenting none of these aggravating factors. The mechanism of agranulocytosis secondary to captopril remains currently debatable, but does not seem, in the present case, to be dose related. Thus, a captopril prescription must comply with certain rules; decrease of the dosage in case of renal insufficiency, usual precautions in patients with collagene diseases. The association to a medication with leucopenic potential is to be avoided. Hematologic monitoring will be adapted to each particular case.

[Myocardiopathies of Friedreich's disease]. / Les myocardiopathies de la maladie de Friedreich.

Cardiac involvement in Friedreich's disease is classically a hypertrophic myocardiopathy, concentric or assymmetrical with or without dilatation. It has nothing specific in comparison to other myocardiopathies. Nevertheless, forms with a dilated myocardiopathy are also possible, but much more unfrequent. A propos of three cases, we have studied the different aspects of myocardiopathies in Friedreich's ataxia. The problem raised by the case of an hypertrophic myocardiopathy evolving toward a dilated form, unusual element of this pathology, is presented. The therapeutic potential of hypertrophic myocardiopathies is classically represented either by beta-blockers or by the more recent slow calcium inhibitors.

[Residual arterial hypertension after excision of an extra-adrenal pheochromocytoma]. / Hypertension artérielle résiduelle après exérèse d'un phéochromocytome extra-surrénalien.

Residual arterial hypertension after excision of a pheochromocytoma of the Zuckerkandl organ, has brought the problem of its etiology. The short term approach consisted in performing, after specific biochemical dosages, a scintigram with IMBG, a scan and a magnetic resonance imaging, to look for a second pheochromocytoma. A negative workup enabled to conclude to an essential arterial hypertension. Nevertheless, this does not exclude the possibility of a long term malignancy, requiring clinical monitoring and IMBG scintigraphy.

[Left intraventricular thrombosis. From diagnosis to treatment]. / Thrombose intraventriculaire gauche. Du diagnostic au traitement.

Left ventricular thrombi are the source of much concern in numerous conditions affecting the ventricles. Refinement in echocardiographic and isotopic techniques is enabling earlier diagnosis and a more rational approach to therapy. These thrombi occur very frequently, and are most often asymptomatic (more than 2 to 3 times out of 4), and their natural course is not well known. Recent studies have dealt with acute ischemic cardiopathies, but these should not obscure the fact that thrombi occur with similar frequency in chronic conditions, in particular, hypokinetic cardiomyopathies. Three recent cases emphasize this, demonstrate the frequency of these thrombi, and help illustrate available diagnostic methods and a practical approach to this condition. These recent developments only confirm the importance of effective anticoagulation in all patients at risk and the necessity of optimal treatment with inotropic agents which do not suppress thrombus formation, but appear to prevent their complications.