[Does hypoalbuminemia contribute to the worsening of heart failure?] / L'hypo-albuminémie contribue-t-elle à l'aggravation de l'insuffisance cardiaque ?

BACKGROUND: Hypoalbuminemia has now emerged as a powerful prognosticator in heart failure regardless of age, clinical presentation, left ventricular ejection fraction and usual prognostic markers. Growing evidence is that this prognostic value persists after adjusting for causative factors for hypoalbuminemia such as malnutrition, inflammation and liver dysfunction. OBJECTIVE: To address the prognostic relevance of hypoalbuminemia in frail elderly patients with well-characterized cardiogenic pulmonary edema at high risk for adverse outcome, beyond causative factors for low serum albumin levels. Serum albumin was measured after clinical stabilization to avoid hypervolemia. RESULTS: In all, 67 patients with a mean age of 86 years were included. Hospital mortality was 30%. Patients who died and who survived were similar in age, ejection fraction, BNP concentration, serum creatinine, serum hemoglobin, total bilirubin and prealbumin. Patients who died had lower serum albumin levels (P<0.001), higher blood urea nitrogen (P=0.03) and higher C-reactive protein (P=0.02). In multivariate analysis, serum albumin was the sole independent predictor of hospital death (P<0.01), after adjusting for malnutrition (prealbumin P=ns), inflammation (C-reactive protein P=ns) and liver dysfunction (total bilirubin P=ns). CONCLUSION: Serum albumin is a powerful prognosticator in frail elderly patients with acute cardiogenic pulmonary edema even after adjusting for main causative factors. These results suggest that hypoalbuminemia may contribute to the worsening of heart failure given the physiological properties of serum albumin that includes antioxidant activity and plasma colloid osmotic pressure action. Further studies are critically needed to address the relevance of prevention and correction of hypoalbuminemia in heart failure.

[Comparative value of B-type natriuretic peptide and serum albumin concentration in the prediction of in-hospital mortality in elderly patients admitted for acute severe heart failure]. / Valeur prédictive comparée de mortalité hospitalière du peptide natriurétique de type B et de l'albuminémie chez le sujet âgé hospitalisé pour insuffisance cardiaque aiguë sévère.

OBJECTIVE: To address the clinical relevance of serum albumin and B-type natriuretic peptide (BNP) concentration in the prediction of in-hospital death in elderly patients with acute severe heart failure. PATIENTS AND METHODS: Seventy-four consecutive patients >70 years of age admitted for acute heart failure in NYHA class IV were prospectively included. BNP concentration was measured on admission and serum albumin concentration after clinical stabilization. RESULTS: Mean age was 86.6+/-5.7 years. Sixty-five percent of patients had a normal left ventricular ejection fraction. Eighteen patients died during the in-hospital stay. Those patients who died were older, had higher blood urea nitrogen and BNP concentration, had lower systolic blood pressure and serum albumin concentration than patients who survived. Heart rate, rhythm, left ventricular ejection fraction, serum creatinine and hemoglobin did not differ according to outcome. By multivariate analysis, albumin (p=0.0017), BNP (p=0.016) and age (p=0.03) were independent predictors of in-hospital death. Serum troponin I measured on admission in 71 patients was predictive of in-hospital death (p=0.01), as well as serum total cholesterol measured after stabilization in 66 patients (p=0.004). However, these two variables no longer predicted outcome in multivariate models, unlike serum albumin and BNP. CONCLUSION: Serum albumin and BNP offer independent, additional information for the prediction of in-hospital death in elderly patient with acute severe heart failure regardless of left ventricular ejection fraction.

[Usefulness of B-type natriuretic peptide (BNP) for the diagnosis of new-onset heart failure with a preserved left ventricular systolic function in longstanding hypertensive patients with acute dyspnea]. / Apport du peptide natriurétique de type B dans le primo-diagnostic d'insuffisance cardiaque à fonction systolique preservée chez le patient hypertendu souffrant de dyspnée aiguë.

BACKGROUND: B-type natriuretic peptide (BNP) has been largely validated in the etiologic diagnosis of acute dyspnea. Nevertheless, its reliability in the setting of a preserved left ventricular systolic function (ejection fraction >50%) has not been adequately established. OBJECTIVE: the study addressed the usefulness of BNP in the diagnosis of new-onset heart failure with a preserved systolic function in hypertensive patients hospitalized for acute dyspnea. METHODS: 59 consecutive hypertensive patients without history of heart failure and coronary disease were included. BNP was measured at presentation with the Triage system. Noninvasive estimation of left ventricular filling pressures by bedside tissue Doppler echocardiography at presentation was incorporated in the diagnostic criteria. RESULTS: the 30 patients with heart failure were not significantly different from the 29 patients with noncardiac cause of acute dyspnea regarding age, gender, body mass index and ejection fraction. Median levels of BNP were significantly higher in heart failure (447 [245-644] versus 87 [43-139] pg/mL). By multivariate logistic regression analysis, BNP (odds ratio of 44, [3.6-531], p=0.003) provided independent and incremental diagnostic information over the clinical score of Boston criteria (2.25, [1.3-3.9], p=0.0037). A BNP value of >142 pg/mL (area under the ROC curve of 0.89, p<0.0001) was 93 sensitive and 79% specific for the diagnosis of heart failure in this setting. CONCLUSION: BNP is a reliable biomarker of new-onset heart failure with a preserved systolic function in hypertensive patients, in particular older, hospitalized for acute dyspnea and can be safely integrated in the diagnostic strategy.

[Prognostic value of BNP for hospital mortality in elderly subjects hospitalised for acute diastolic cardiac failure]. / Valeur pronostique du BNP pour la mortalité hospitalière chez le sujet agé hospitalisé pour insuffisance cardiaque diastolique aiguë.

The aim of this study was to evaluate the prognostic value of BNP in elderly patients hospitalised for acute diastolic cardiac failure. 108 consecutive subjects were included, aged at least 70 years old, hospitalised for isolated acute diastolic cardiac failure. All of them had a left ventricular ejection fraction > or = 50% and evidence of diastolic dysfunction on echocardiography performed shortly after admission. The plasma BNP concentration measured in the emergency department on admission was >100 pg/ml in all of the patients except five. It was positively correlated with age (R = 0.29, p = 0.002), with the plasma creatinine level (R = 0.37, p < 0.0001) and the plasma urea level (R = 0.41, p < 0.0001). On univariate analysis, compared to the patients who survived, the 20 patients who died before discharge were significantly older (88.6 versus 84.4 years, p = 0.01), and were more often residents of a care home (60 versus 31%. p = 0.02), had a lower systolic blood pressure on admission (127 +/- 33 versus 154 +/- 30 mm Hg), a higher plasma urea level (16.8 +/- 12 versus 8.9 +/- 5 mmol/l, p = 0.002) and a higher BNP (median = 1290 pg/ml, interquartile range: 721, 3026 pg/ml versus 430 pg/ml, interquartile range: 243, 886 pg/ml). On multivariate analysis, the only factors that remained significantly associated with mortality were the BNP levels (p = 0.005) and the systolic blood pressure (p = 0.01). The negative predictive value of a BNP level < 631 pg/ml (median) for death was 94% (95% confidence interval: 91 to 97%). We conclude that BNP does have an independent prognostic value for in-hospital death in elderly subjects with acute diastolic cardiac failure.

[Novel Doppler indexes of estimation of pulmonary capillary pressure: influence of age, feasibility in the acute setting and reproducibility]. / Nouveaux indices doppler d'estimation de la pression capillaire pulmonaire: influence de l'âge, faisabilité en situation aiguë et reproductibilité.

BACKGROUND: The Doppler indexes E/Vp, E/Ea, 1000/(2 x IRT + Vp), 1000/(2 x IRT + Ea) and DTd (E: peak E mitral velocity; Vp: flow propagation velocity by color M-mode; Ea: peak early diastolic velocity at lateral mitral annulus by tissue Doppler; IRT: isovolumic relaxation time; DTd: deceleration time of the pulmonary venous diastolic wave) have been proposed for the non-invasive prediction of left ventricular filling pressures. However, the influence of age, the feasibility in acute setting and the reproducibility of these Doppler indexes have never been simultaneously investigated. OBJECTIVE: The present study was conducted to evaluate the influence of age in 56 healthy subjects (57 +/- 20 years of age), the feasibility in 40 critically ill patients (72 +/- 13 years of age; 21 with decompensated heart failure) and the reproducibility in 15 patients. RESULTS: Only the indexes E/Vp (R = 0.37, P = 0.005) and E/Ea (R = 0.72, P < 0.001) were correlated with age. The feasibility was 92, 90, 72, 72 and 45% for E/Ea, 1000/(2 x IRT + Ea), E/Vp, 1000/(2 x IRT +Vp) and DTd, respectively. The best reproducibility was observed for the Doppler parameters E and Ea. CONCLUSION: Despite it is influenced by age, E/Ea appears to be the most useful index for predicting left ventricular filling pressures routinely.

[Value of Doppler indices of diastolic left ventricular dysfunction in acute cardiac insufficiency]. / Valeur des indices Doppler de dysfonction ventriculaire gauche diastolique dans l'insuffisance cardiaque aiguë.

OBJECTIVE: To examine the prevalence of diastolic dysfunction by Doppler study in acute cardiac failure. CONTEXT: A recent study showed that diastolic dysfunction is constant in stable cardiac failure with preserved systolic function and suggested that its measurement was not necessary for the diagnosis of diastolic cardiac failure, but the prevalence of diastolic dysfunction in acute cardiac failure is not known. METHOD: The mitral and pulmonary venous profiles, the propagation velocity Vp of colour filling flow, and the lateral velocity Ea of the mitral ring in DTI were studied at the time of treatment initiation in 28 patients in sinus rhythm and in acute cardiac failure (11 NYHA IV and 17 with pulmonary oedema), of whom 18 had an ejection fraction greater than 50%. RESULTS: Diastolic dysfunction was present in the combined study of mitral and pulmonary profiles in 95% and 100% respectively of patients in cardiac failure with preserved systolic function and altered systolic function, and Vp < 45 and/or Ea < 8 cm/s was observed in 55% and 100% respectively of these patients. At respective pathological threshold values of 1.5 and 10, the combined indices E/Vp and E/Ea were concordant with the evaluation of filling pressures in 83% of patients with preserved systolic function and 100% of the systolic cardiac failure cases. CONCLUSION: Diastolic dysfunction is almost constant in acute cardiac failure independently of the ejection fraction value. However, normal values of Ea and Vp do not exclude the diagnosis of diastolic cardiac insufficiency in the acute situation.

[Silent ischemia and acute cardiac insufficiency with normal systolic function: diagnostic value of troponin I measurement]. / Ischémie silencieuse et insuffisance cardiaque aiguë à fonction systolique conservée: intérêt diagnostique du dosage de la troponine I.

The physiopathological mechanisms resulting in increased left ventricular pressures in acute cardiac failure with normal systolic function are not well understood. Although coronary artery disease is commonly associated with acute episodes, the diagnostic value of troponin I measurement and the prevalence of ischaemia as the predisposing factor are not known. Twenty coronary patients (mean age 77 +/- 9 years) in acute cardiac failure with left ventricular ejection fractions of 50% or over and without angina, were studied retrospectively. The diagnostic value of troponin I (cTnI, AxSYM, method) was assessed by comparing with a control group of 16 acute cardiac failure patients without coronary disease. The frequency of hypertension and diabetes in the coronary group was 50 and 45% respectively. At the time of investigation, the pulmonary capillary and systemic arterial pressures were comparable in the coronary patients irrespective of the cTnl value. At threshold levels of 0.5 microgram/l, cTnl had a specificity of 100% and confirmed ischaemia in 60% of the coronary patients. Ischaemia was the commonest predisposing factor for increased cardiac pressures. Over a 268 +/- 101 days follow-up period, half the coronary patients were readmitted for acute cardiac failure and a third of them died. The authors conclude that silent ischaemia is a common predisposing factor for acute cardiac failure in coronary patients with normal systolic function and troponin I measurement is a useful diagnostic help.

Hypothalamo-pituitary-adrenal axis in acute myocardial infarction treated by percutaneous transluminal coronary angioplasty: effect of time of presentation.

Acute myocardial infarction (AMI) is associated with a stimulation of cortisol which lasts 24 hours in patients treated by thrombolysis. Percutaneous transluminal coronary angioplasty (PTCA) is an alternative treatment for AMI which reduces the length of myocardial ischemia. Our objective was the determination of the amplitude and duration of cortisol and other hormones of the hypothalamo-pituitary-adrenal (HPA) axis release in patients undergoing PTCA. These responses were also analyzed in relation with the time of onset of AMI. The effect of coronarography with or without angioplasty in patients without AMI was also studied. Plasma ACTH, cortisol, corticotropin-releasing hormone and arginine vasopressin levels were determined during the first 48 hours in 20 patients with first AMI, treated by PTCA and in 10 patients without AMI undergoing coronarography (and angioplasty in five of them). A strong stimulation of the HPA axis was observed in AMI patients, but the duration of cortisol secretion was significantly reduced (less than 8 hours) as compared with previous studies in patients treated with thrombolysis. A clear-cut ACTH-cortisol dissociation was also observed after the third hour. ACTH and cortisol stimulation was higher in patients admitted between 04:00 h and 16:00 h than in patients admitted between 16:00 h and 04:00 h In patients without AMI, coronarography induced a moderate, but significant short-lasting ACTH and cortisol stimulation. In conclusion, our data suggest that the degree of stimulation of the HPA axis may depend upon the type of treatment and the circadian rhythm of this axis.

[Study of non-invasive hemodynamic parameters in pulmonary edema: hypoalbuminemia is a factor frequently associated with acute diastolic cardiac insufficiency]. / Etude des paramètres hémodynamiques non invasifs dans l'oedème pulmonaire: l'hypo-albuminémie est un facteur favorisant fréquent de l'insuffisance cardiaque diastolique aiguë.

SUBJECT: A critical diminution of the gradient between plasma oncotic pressure (PO) and pulmonary capillary pressure (PCP) is the origin of the formation of haemodynamic pulmonary oedema (OAP), but the respective contribution of these two haemodynamic forces as a function of the type of cardiac insufficiency is not known. METHOD: 74 cases of OAP were included (78 +/- 15 years old, 43 diastolic defined by an ejection fraction greater than 45%, and 31 systolic), and 33 control subjects. PO and PCP were calculated respectively from total protein and albumin serum levels, and from transthoracic echocardiography with the new Doppler indices using refilling flow propagation speed in colour TM or the study of pulmonary venous flow, at the start of treatment. RESULTS: The gradient was very significantly diminished in those with diastolic and systolic cardiac insufficiency compared to the control group (p < 0.001), with no difference between the two types of OAP. An elevation of PCP > or = 18 mm Hg was the principal haemodynamic factor in the critical diminution of the gradient in the systolic group and in the diastolic group with ischaemic or valvular cardiopathy. In parallel with the elevation in PCP was a state of plasma hypo-oncocity < or = 18 mm Hg, consecutive with a significant diminution of albuminaemia, contributing to the critical diminution of the gradient in 41% of diastolic cases versus 3% of systolic cases. CONCLUSION: Hypo-albuminaemia is a factor frequently favouring acute diastolic cardiac insufficiency in elderly subjects and must be sought systematically.

[Usefulness in clinical practice of noninvasive measurement of colloids osmotic pressure-capillary pulmonary pressure gradient in the management of acute dyspnea]. / Intérêt en pratique clinique de la mesure non invasive du gradient pression oncotique-pression capillaire pulmonaire dans la prise en charge d'une dyspnée aiguë.

BACKGROUND: Increased pulmonary capillary pressure (PAWP) and decreased serum colloid osmotic pressure (COP) are important factors in pulmonary edema (PE) formation. The aim of this study was to evaluate the clinical usefulness of noninvasive determination of COP, PAWP and COP-PAWP gradient in patients with acute dyspnea. METHODS: Thirty four patients presenting with PE, 19 with preserved left ventricular systolic function (Ia) and 15 with depressed systolic function (Ib), and 26 patients presenting with acute pulmonary diseases (II) were enrolled. COP was estimated using Landis and Pappenheimer formula (COP = 2.1 x P + 0.16 x P2 + 0.009 x P3, P: serum total protein concentration). PAWP was measured by transthoracic Doppler echocardiography using E/Vp and 1000/(2 x IPT + Vp) Doppler indexes. RESULTS: The mean value of the gradient was 0.5 +/- 5, 1.7 +/- 3.4 and 10.4 +/- 4.7 mmHg in Ia, Ib and II respectively (P < 0.001 Ia and Ib vs II). PAWP was higher in Ia and Ib than in II (P < 0.001). However, hypoalbuminemia with COP < or = 18 mmHg was observed in 63% of patients in Ia as compared to those in Ib (7%) and II (8%). CONCLUSIONS: Severe hypoalbuminemia frequently contributes to PE formation in the presence of normal left ventricular systolic function. A COP-PAWP gradient value lower than 6 mmHg is highly predictive of the diagnosis of acute heart failure in these patients presenting with acute dyspnea.

[Cardioversion by external electric shock for atrial fibrillation: does patient age affect immediate results?]. / Cardioversion par choc électrique externe de la fibrillation auriculaire: l'âge des patients affecte-t-il les résultats immédiats?

The restoration of sinus rhythm by external electric shock in patients with persistent atrial fibrillation is a well established treatment. However, in current practice this treatment is generally indicated less in the elderly subject although this attitude is not factual. The objective of this work was to evaluate the immediate results of cardioversion by external electric shock, comparing the success rates in four age groups: under 60 years, between 60 and 69 years, between 70 and 79 years, and over 80 years. This study was performed on 182 consecutive patients aged from 25 to 89 years: 35 patients aged less than 60 years, 52 patients aged from 60 to 69 years, 65 patients aged from 70 to 79 years, and 30 patients aged 80 years or over. The success rates were 91.4% before 60 years, 90.4% between 60 and 69 years, 90.8% between 70 and 79 years, and 83.3% after 80 years. There was no significant difference between the success rates in the four age groups (p = 0.68). Among the other factors analysed, only the duration of atrial fibrillation and the body mass index significantly influenced the results of external electric shock in this series. This work suggests that age does not significantly influence the immediate results of external electric shock. According to these data it does not appear justified to contra-indicate cardioversion by external electric shock on the sole criterion of age.

[Usefulness of Doppler echocardiography in the diagnosis of acute diastolic heart failure in the elderly]. / Apport de l'échocardiographie Doppler dans le diagnostic de l'insuffisance cardiaque aiguë à fonction systolique conservée du sujet âgé.

PURPOSE: To evaluate the clinical usefulness of the determination of Doppler mitral inflow pattern and new combined indices using colour M mode velocity flow propagation (Vp) in the diagnosis of acute diastolic heart failure in the elderly. METHODS: Total serum protein concentration (P, g/l) and E/A, E/Vp and 1000/(2 x IRT + Vp) Doppler indices (E and A: mitral inflow peak velocities; IRT: isovolumic relaxation time) were measured at the time of therapy initiation in 94 patients with left ventricular ejection fraction > 50% (78 +/- 13 years), 56 with pulmonary edema and 38 patients with acute respiratory disease. RESULTS: The feasibility was 73, 90 and 89% for E/A, E/Vp and 1000/(2 x IRT + Vp) respectively. The sensitivity, specificity and accuracy were 94-56-72%, 84-86-85% and 92-86-89% for E/A > or = 1, E/Vp > or = 2 and 1000/(2 x IRT + Vp) > or = 6 respectively in the diagnosis of pulmonary edema in patients with normal serum colloid osmotic pressure defined by P > or = 60 g/l, and 41-50-43%, 37-86-50% and 22-100-42% in patients with low colloid osmotic pressure (P < 60 g/l). CONCLUSIONS: The mitral inflow measurement is limited in most of cases of acute diastolic heart failure in the elderly by confounding factors such as atrial fibrillation and normalised pattern. New combined Doppler indices are useful in these patients, however, their value must be interpreted according to the serum colloid osmotic status estimated by total serum protein concentration.

Influence of residual myocardial ischaemia on induced ventricular arrhythmias following a first acute myocardial infarction.

OBJECTIVES: The purpose of this study was to assess the possible effect of residual myocardial ischaemia on induced ventricular arrhythmia during programmed ventricular stimulation in survivors of a first acute myocardial infarction. BACKGROUND: Most deaths after hospital discharge for acute myocardial infarction are sudden and presumably arrhythmic. Sudden cardiac death results from a dynamic interaction of structural abnormalities and transient triggering factors. The role of myocardial ischaemia as a trigger for ventricular arrhythmias remains unclear. We hypothesized that residual myocardial ischaemia after a first acute myocardial infarction is a potent trigger for sustained ventricular tachyarrhythmias, particularly in the presence of an abnormal myocardium. METHODS AND RESULTS: In this prospective study, programmed electrical stimulation, coronary angiography and dipyridamole-thallium-201 scintigraphy single-photon emission computed tomography were performed in 90 consecutive survivors of a first acute myocardial infarction. Patients, divided in two groups - group 1 with induced ventricular tachyarrhythmia (n=24) and group 2 without induced ventricular tachyarrhythmia (n=66) - were compared regarding residual myocardial ischaemia. The two groups were comparable in terms of mean left ventricular ejection fraction, infarct size and location, gender ratio, peak creatine kinase value, and extent of coronary disease. Residual myocardial ischaemia was detected in 32 patients: 15 (42.5%) belonged to group 1 and 17 (25.7%) to group 2. There was a statistically significant difference between the two groups regarding the presence and the extent of residual myocardial ischaemia (P<0.05). CONCLUSION: Residual myocardial ischaemia, revealed by dipyridamole-thallium-201 scintigraphy following a first acute myocardial infarction, might contribute to electrical instability evaluated by programmed ventricular stimulation.

Effects of digoxin on chemoreflex in patients with chronic heart failure.

The effects of digitalis on the baroreflexes in human chronic heart failure have been well studied. Similarly, since it has been recently shown that chemoregulation remains generally effective during cardiac failure, the goal of this study was to evaluate the effects of a chronic administration of digoxin on the chemoreflexes. Hemodynamic and blood gas parameters were assessed in 7 patients with chronic congestive heart failure before and after chronic administration for 10 days of digoxin therapy (0.25 mg daily). In both situations measurements were performed 1/ in baseline conditions at room air and, 2/ after inhalation of pure O2 for 30 min, in order to inhibit the activation of the chemoreflexes. At room air, acute O2 inhalation resulted in a significant decrease in heart rate and cardiac output. After digoxin therapy, comparatively to pre-treatment values, cardiac output, stroke volume and PaO2 were significantly higher while heart rate, systemic resistance and pulmonary wedge pressure were lower. Furthermore, acute O2 inhalation did not modify heart rate or any hemodynamic variables. These results suggest that after digoxin therapy chemoreflex was no more activated in these patients. This effect may be related to the sympatho-inhibitory and to the positive inotropic effects of digoxin: improving hemodynamic and blood gas parameters may result in the inactivation of the reflex.

Inducible ventricular arrhythmias and patency of infarct-related artery in survivors of acute myocardial infarction.

BACKGROUND: Patency of infarct-related artery in patients who suffered an acute myocardial infarction (AMI) has been shown to be associated with improved survival. Ventricular tachyarrhythmias induced by programmed electrical stimulation may be predictive of arrhythmic events and sudden death. HYPOTHESIS: The study was undertaken to assess the possible effect of a patent infarct-related coronary artery on induced ventricular tachyarrhythmias during programmed ventricular stimulation in survivors of AMI. METHODS: In this prospective study, programmed electrical stimulation was performed before hospital discharge (14 +/- 2 days) in 79 patients who survived an AMI. Patients were subdivided into two groups: Group I with patent infarct-related coronary artery (n = 64) and Group 2 with occluded infarct-related artery (n = 15) at coronary angiography performed at 14 +/- 2 days. These two groups were comparable in terms of mean left ventricular ejection fraction, location of infarct-related artery, number of diseased vessels, peak creatine kinase value, and infarct location. RESULTS: Ventricular arrhythmias were induced in 21 patients ( 32.6%) of Group I and 4 patients (26.6%) of Group 2. This difference was not statistically significant. CONCLUSION: This study suggests that ventricular arrhythmias induced by programmed ventricular stimulation in survivors of AMI did not differ whether the infarct-related artery was patent or occluded. Other factors may play a role in electrical instability as assessed by programmed ventricular stimulation.

[Tolerance and efficacy of carvedilol prescription in patients with mild to moderated chronic heart failure]. / Tolérance et efficacité du carvédilol prescrit chez des patients atteints d'insuffisance cardiaque chronique légère à modérée.

The current treatment for heart failure, i.e., carvedilol administration, has brought about a significant reduction in cardiovascular morbidity and mortality. The European Cardiology Association task-force has recently recalled that the treatment for heart failure should be considered differently according to the regions within Europe. However, most studies have involved North American or Australasian subjects. The results of these studies have shown that carvedilol improves the symptomatic status of patients with mild to moderate chronic heart failure, but their extrapolation to the situation in Europe is questionable. In the present study, the authors have reported on the use of this beta-blocker over a 6-month period in 48 European subjects (an older patient population, and more frequently given digitalis treatment) with mild to moderate stage II and III chronic heart failure (mean NYHA functional stage = 2.75 +/- 0.2; mean left ventricular ejection fraction = 32.4 +/- 3.4). Six patients (12.5%) were obliged to withdraw from the study due to adverse reactions to carvedilol, i.e., 2 subjects during the test-dose (4.2%) and 4 others who were subsequently unable to withstand the progressive stepping up of drug dosage (8.3%). In the remaining 42 patients, the mean NYHA scores dropped significantly from 2.75 +/- 0.2 to 1.8 +/- 0.1 (p < 0.05) at the end of the study period, indicating an increase in symptomatic improvement with a favorable hemodynamic tolerance profile, even in cases of combined therapy with digitalis. This study confirms the positive action of carvedilol on functional symptomatology in southern European patients presenting with mild to moderate chronic heart failure. However, it should be emphasized that this beta-blocker should only be administered under strict and specialized medical surveillance as its effect of significantly slowing down the heart rate could also result in cardiac insufficiency.

[Hereditary resistance to vitamin K antagonists. Apropos of a case]. / Résistance héréditaire aux antivitamines K. A propos d'un cas.

Resistance to vitamin K antagonists is a rare phenomenon. In general, it is the result of poor patient compliance, malabsorption, a diet rich in vitamin K, or the use of enzyme inducers. Occasionally, the diagnosis of resistance is made when plasma levels are high. The authors report a case of hereditary resistance to vitamin K antagonists in a 43 year old man admitted for atrial fibrillation. The precise prevalence of this anomaly is unknown. However, the existence should be known to clinicians who often use this important family of drugs.

Pocket infection complicating inadvertent transarterial permanent pacing. Successful percutaneous explantation.

This report describes a patient admitted for the treatment of a pocket infection occurring 5 months after a dual chamber pacemaker implantation. The ventricular lead had been inadvertently placed into the left ventricle through the arterial system. After careful examination using transesophageal echocardiography and left heart angiogram, successful percutaneous extraction was performed without complication.

[ECG anomalies and axis deviations in heart transplant recipients: MRI studies]. / Anomalies électrocardiographiques et déviation du grand axe du coeur chez les greffés cardiaques: étude par IRM.

The electrocardiogram is often abnormal after orthotopic cardiac transplantation. This study was conducted in order to evaluate the frequency of these abnormalities in a population of 29 patients transplanted according to the conventional mode or the total mode. We also investigated the correlation between these abnormalities and the presence of left ventricular hypertrophy or deviation of the left ventricular long axis. The left ventricular mass was measured by TM echocardiography. The position of the left ventricular long axis was determined by MR on a ultrarapid sequence. The ECG was normal in 5 patients. The abnormalities revealed in the other 24 patients were: an rSr' or rsr' appearance in V1 with a QRS complex less than 0.12 sec in 11 patients, complete right block in 1 patients, repolarization abnormalities (apart from those associated with branch blocks) in 8 patients, left axis deviation of the QRS in 5 patients, a biphasic P wave in V1 with a Morris index greater than 4 mV.sec in 5 patients, and double atrial activity in 3 patients. These abnormalities were observed regardless of the type of transplantation, with the exception of double atrial activity which was only observed in the group of patients undergoing conventional transplantation. On average, the long axis of the left ventricle was more horizontal and deviated to the left compared to age- and sex-matched controls. All patients with left axis deviation of the QRS had left ventricular hypertrophy versus 13 of the 24 patients without QRS axis deviation and abnormalities of position of the anatomical left ventricular long axis. Our results therefore suggest that the frequent presence of right branch block in heart transplant recipients is due to factors other than the position of the heart in the thorax, for example right ventricular hypertrophy.