Antithrombotic therapy is associated with better survival in patients with severe heart failure and left ventricular systolic dysfunction (EPICAL study).

BACKGROUND: In patients with congestive heart failure (CHF), clinical trials have demonstrated the benefit of a number of drugs on morbidity and mortality. Nevertheless so far, there is no published controlled study of long-term antithrombotic therapy in patients with CHF. The aim of this work was to identify the relationship between cardiovascular drug use, especially antithrombotic therapy, and survival of CHF patients in current clinical practice, using an observational, population-based database. METHODS: The EPICAL study (Epidémiologie de l'Insuffisance Cardiaque Avancée en Lorraine) has identified prospectively all patients with severe CHF in the community of Lorraine. Inclusion criteria were age 20-80 years in 1994, at least one hospitalisation for cardiac decompensation, NYHA III/IV HF, ventricular ejection fraction < or =30% or cardiothoracic index > or =60% and arterial hypotension or peripheral and/or pulmonary oedema. A total of 417 consecutive patients surviving at hospital discharge were included in the database. The average follow-up period was 5 years. Univariate Cox models were used to test the relationship of baseline biological and clinical factors to survival. Cardiovascular drug prescriptions were tested in a multivariate Cox model adjusted by other known predictive factors. RESULTS: Duration of disease >1 year, renal failure, serum sodium > or =138 mmol/l, old age, serious comorbidity, previous decompensation, high doses of furosemide and vasodilators use were independently associated with poor prognosis at 1 and 5 years. Oral anticoagulants, aspirin, lipid lowering drugs and beta-blockers use were associated with better survival. There was no interaction between aspirin and angiotensin converting enzyme inhibitor use on survival. CONCLUSION: Antithrombotic therapy was associated with a better long-term survival in our study population of severe CHF. These results together with other previously published circumstantial evidence urge for a prospective, controlled and randomised trial specifically designed to evaluate optimal oral anticoagulants and aspirin in patients with congestive heart failure.

Cardiac angiosarcoma revealed by lung metastases.

Cardiac angiosarcoma is a rare tumour with very poor prognosis especially in patients with metastatic disease. We present the case of a 43 year old patient with angiosarcoma revealed by open lung biopsy for multiple pulmonary metastases. Cardiac symptoms were limited to a moderate pericarditis and no echocardiographic sign of heart tumour was observed. The clinical outcome was rapidly fatal despite chemotherapy. The cardiac primary tumour was diagnosed at autopsy. We emphasize the difficulties of diagnosing cardiac angiosarcoma and confirm the limited value of echocardiography for this diagnosis.

[Efficacy, tolerance and incidence of risk factors of Alpress in the treatment of arterial hypertension]. / Efficacité, tolérance et incidence sur les facteurs de risques de l'Alpress dans le traitement de l'hypertension artérielle.

The system release of prazosin confirms the good efficacy and tolerance of Alpress in the hypertension treatment. Prazosin has favorable effects on some risk factors, and it therefore seem interesting to conduct a study in a pannel of hypertensive patients, to emphasize the quality of Alpress response, based on these criteria. This experiment demonstrated the efficacy and tolerance levels of Alpress as well as its favorable effect on cholesterol.

[Prognostic value of a new perfusion index calculated from coronarography]. / Valeur pronostique d'un nouvel index de perfusion calculé à partir de la coronarographie.

A new perfusion index was determined from the study of the coronary vascular bed in 8 myocardial territories: upper septal, lower septal, upper anterior, lower anterior, apical, lateral, posterior and inferior. Stenosis of a vessel reduces perfusion in all territories fed by that vessel, downstream of the stenosis. The perfusion index is calculated by adding up the lesions in all 8 territories. In a population of 418 consecutive patients who had undergone coronary arteriography in 1972 and 1973, survival was evaluated according to the perfusion index and to those parameters which classically have the greatest influence on survival. The perfusion index came out as the most important prognostic factor since such parameters as the number of stenotic vessels and ventricular kinetics lose their prognostic value when adjusted to that index. According to the perfusion index, the 8-year prognosis is the same as in subjects without coronary disease when the reduction in overall perfusion does not exceed 40%. With a 40 to 79% reduction the death risk at 8 years is 30% whatever the exact percentage in each individual. When perfusion is reduced by 80% the death risk at 8 years rises to 72%. This perfusion index, easy to determine, provides a better evaluation of prognosis than the conventional parameters.

Echocardiographic features of right atrial thrombi.

The clinical and echocardiographic features of six patients in whom a right atrial thrombus was detected using two-dimensional echocardiography are reported. In four patients with acute cor pulmonale, the thrombus appeared as a coiled mass moving freely within the right atrium and prolapsing through the tricuspid valve. In another patient referred for syncope, a large coiled mass attached to the lateral wall of the right atrium was seen prolapsing regularly through the tricuspid valve, simulating an atrial myxoma. In the remaining patient who presented with chronic cor pulmonale, two-dimensional echocardiography demonstrated a motionless ovoid mass with a broad base of attachment to the interatrial septum.

[Clinical, echocardiographic and evolutive aspects of right atrial thrombosis]. / Aspects cliniques, échocardiographiques et évolutifs des thromboses de l'oreillette droite.

The clinical and echocardiographic features of right atrial thrombi were examined in 9 patients, 5 men and 4 women aged 16 to 86 years. The 2D echocardiographic diagnosis was confirmed at autopsy (4 cases) or by the association of severe recurrent pulmonary embolism (5 cases). Three patients had associated ischaemic heart disease and on patient had dilated cardiomyopathy. The clinical presentation was: acute cor pulmonale (5 cases including 2 patients which biventricular myocardial infarction), chronic post-embolic cor pulmonale (1 case), tricuspid valve obstruction (1 case), general ill health with pyrexia (1 case) and heparin-induced thrombocytopenia (1 case). Predisposing factors included: absence of anticoagulent therapy (7 cases), previous supraventricular arrhythmias (2 cases) and right ventricular failure (6 cases, including 2 of right ventricular infarction). In 2 patients the thrombi were relatively immobile and had a wide base of implantation on the interatrial septum; in 1 patient, multiple thrombi were observed lining the right heart cavities from the inferior vena cava to the pulmonary infundibulum. In the other 6 patients, the thrombi were very mobile with a visible pedicule of implantation (2 cases) or totally free (4 cases). The variable polylobulated appearances, completely irregular whirling motion and intermittent prolapse into the tricuspid valve were characteristic features of the latter 4 cases. They disappeared spontaneously (2 cases) or after fibrinolytic therapy (2 cases) in under 36 hours. Three patients were operated with one postoperative death. The global hospital mortality was 22%. The present occasional detection of right atrial thrombosis will certainly become more common if patients with pulmonary embolism, right ventricular infarction or deep venous thrombosis are systematically examined by 2D echocardiography in the acute phase of their illness.

[Compressive pericardial effusion after heart surgery in the adult. Contribution of bidimensional echocardiographic findings]. / Epanchement péricardique compressif après chirurgie cardiaque de l'adulte. Apports de l'échocardiographie bidimensionnelle.

In series of 1450 consecutive cardiopulmonary bypasses for cardiac surgery in adults, we observed 20 cases of post-operative compressive pericardial effusion. The effusion occurred some time after the thoracic drains were removed and had to be evacuated. Two-dimensional echocardiography proved essential to the diagnosis : it easily detected the lesion even when clinical symptoms were misleading but above all, it demonstrated, in our series, that the classical post-operative "tamponade" is a specific entity consecutive to posterior, circumscribed, small volume effusions which mainly compress the left cardiac cavities.

[Apical hypertrophic cardiomyopathy: an element in the continuum of hypertrophic cardiomyopathies]. / La cardiomyopathie hypertrophique apicale: un élément du continuum des cardiomyopathies hypertrophiques.

Fourteen cases of apical hypertrophic cardiomyopathy (i.e. hypertrophy localized to the distal half of the left ventricular wall) are reported. There were 12 men and 2 women aged from 21 to 84 years. Only one of the patients presented, at first consultation, with severe functional symptoms, namely stage IV dyspnoea. ECG tracings were always abnormal, but the classical giant T waves were found in only 7 patients. In the 9 patients who had cardiac catheterization the left ventricular end-diastolic pressure was raised, and angiography showed an "ace of spades" diastolic image of the left ventricle with systolic obliteration of its tip. The distribution of parietal hypertrophy was best studied by two-dimensional echocardiography: the left ventricular apex was affected alone in 7 patients and concomitantly with the adjacent segments of the left or right ventricle in the other 7 patients. A family study showed that 3 patients had a descendant with obstructive cardiomyopathy. At a 4.6 years' follow-up the course of the disease was usually favourable. Apical hypertrophic cardiomyopathy is not a particular entity but one of different possible forms of hypertrophic cardiomyopathy. It seems to be benign in most cases.

[Infarction of the right ventricle. Contribution of two-dimensional echocardiography]. / Infarctus du ventricule droit. Apport de l'échocardiographie bidimensionnelle.

This study, based on 39 cases, confirms the value of two-dimensional echocardiography in the diagnosis of right ventricular infarction during the acute phase. This diagnosis is confirmed by the presence of abnormalities of the segmental kinetics always present in the inferior wall and less frequently in the anterior wall. The inferior part of the septum is affected in two thirds of cases. Right ventricular dilation is frequently observed, but is not constant. Two-dimensional echocardiography has a diagnostic sensitivity similar to that of isotope ventriculography, but greater than that of haemodynamic investigations. Finally, apart from the easy demonstration of complications (tricuspid incompetence, septal rupture, intracardiac thrombosis), two dimensional echocardiography can be used to evaluate right ventricular function.

[Spasm in a single coronary artery]. / Spasme sur coronaire unique.

A 52 year old man presented with effort and resting angina with positive exercise stress testing and myocardial scintigraphy. The initial coronary angiogram showed a single coronary vessel arising from the right coronary ostium dividing into a right coronary artery with a normal trajectory lined with a few non stenotic atheromatous plaques and a left coronary artery which passed between the aorta and pulmonary artery to reach the left atrioventricular groove. At first, it was suggested that the angina was due to compression of the left coronary vessel by the great arteries during effort, but this mechanism could not explain attacks of resting angina and the failure of betablocker therapy. An ergometrine test performed during repeat coronary angiography induced almost complete occlusion of the right coronary vessel and Prinzmetal diaphragmatic ischaemia. The anginal attacks were completely suppressed by Calcium antagonist drugs. The association of coronary spasm and a single coronary artery is rare; only one case has been previously reported. We do not believe that there was a relationship between the two phenomena in our case: the spasm occurred at a distance from the aberrant course of the vessel. The authors emphasise the diagnostic problems and the potential danger of this association.

[Apical hypertrophic myocardiopathy. Apropos of 10 cases]. / Myocardiopathie hypertrophique apicale. A propos de 10 observations.

Apical hypertrophic cardiomyopathy is a recently defined subgroup of primary hypertrophic cardiomyopathy. Ten new cases are studied. The electrical features (anomalies of repolarisation) were constant and giant negative T waves were observed in 3 out of 10 cases. Two-dimensional ultrasonography confirmed the diagnosis in every case; the optimal views consisted of 4 cavity scans obtained by the apical approach. When angiography was performed (7 cases out of 10), it confirmed the ultrasonographic findings and was able to eliminate any coronary artery lesions. The patients had a mean age of 48.3 years with a marked male predominance (sex ratio of 0.8) and all of the patients are alive with a mean follow-up of 3.4 years. The functional handicap was moderate (class III: 1 case, class II: 5 cases and class I: 4 cases) and did not progress during the period of follow-up. The family surveys performed revealed that apical hypertrophy can be integrated into the spectrum of segmental hypertrophic cardiomyopathy. In two cases, this survey revealed the coexistence in the same family of segmental hypertrophy with different topography. The long term prognosis of this disease is unknown and the authors consider that the risk of ventricular arrhythmia justifies routine rhythmological evaluation in order to guide subsequent treatment.

Prophylactic effect of intravenous tiapamil on methylergometrine-induced coronary artery spasm in patients with variant angina: randomized double-blind trial.

Tiapamil is a new calcium entry blocker. The ability of its intravenous form to prevent methylergometrine-induced coronary artery spasm was studied in 11 consecutive patients with angiographically documented vasospastic angina. The study was designed as a double-blind crossover trial of tiapamil vs placebo. Each patient received, in a randomized order, either tiapamil, as a 1.5 mg/kg intravenous bolus followed by a 50 micrograms/kg/min infusion lasting 3 hours, or a matched placebo. Immediately after the infusion, methylergometrine tests were performed with up to 0.4 mg of methylergometrine or until a positive ECG was recorded. Compared to the values obtained after placebo infusion, tiapamil significantly lowered systolic and diastolic blood pressure (respective pre- and posttiapamil values: 119.9 +/- 17.7 vs 142.1 +/- 25.5 mm Hg, p less than 0.01; and 72.0 +/- 9.1 vs 82.4 +/- 9.3 mm Hg, p less than 0.02); the drug exerted no significant effect on heart rate (63.9 +/- 13.3 vs 67.6 +/- 16.5 bpm, NS), PR interval (0.180 +/- 0.020 vs 0.177 +/- 0.017 sec NS), or QTc interval (404.4 +/- 16.5 vs 396.0 +/- 26.6 msec, NS). After placebo, 10 patients had positive methylergometrine tests following single doses ranging from 0.1 to 0.4 mg. The remaining patient developed ventricular bigeminy, which resolved immediately after administration of isosorbide dinitrate; his test was therefore considered negative in the evaluation of the results. In contrast, after tiapamil, eight patients had negative tests for doses of up to 0.4 mg methylergometrine, and three had positive tests for the same methylergometrine doses as after the placebo.(ABSTRACT TRUNCATED AT 250 WORDS)

[Sudden death in mitral valve prolapse. Apropos of 2 cases]. / La mort subite du prolapsus valvulaire mitral. A propos de deux cas.

Two cases of sudden death are reported in patients with mitral valve prolapse with mitral insufficiency. Both had significant impairment of left ventricular function. Irreversible ventricular fibrillation occurred in one patient one-half hour preceding a catheterization, whereas the other patient died during sleep. Review of the literature revealed 42 cases of sudden death in patients with prolapse. Occasionally left ventricular dysfunction or medication overdosage can explain or favor development of the terminal arrhythmia, but usually no precipitating factor other than prolapse can be identified. It appears impossible to identify actual subgroups at risk, although sudden death does occur more frequently in patients with a large amount of prolapse of both valves, previous syncopal episodes, and ECG abnormalities at rest. Complex ventricular arrhythmias are also reported, but their predictive importance is difficult to evaluate. Sudden death is a rare complication of mitral prolapse, fact which should conservatively influence indications for further supplementary testing and treatment in these patients.

[Sudden death in athletes]. / La mort subite chez le sportif.

In order to study the etiologies and mechanisms in sports-related sudden death, the author selected 198 cases from the world literature which met the following criteria: subjects were less than 40 years of age and in good physical condition, death occurred at the latest 1 hour after the physical activity, there was no known heart disease, and an autopsy had been performed. In spite of the heterogeneous character of those subjects included in this study and numerous biases, the following results were obtained: in some cases, the mechanism underlying the sudden death could be confirmed by autopsy (massive myocardial infarction, rupture of the aorta, cerebral hemorrhage), and in others it appeared highly probable (atheromatous or congenital coronary artery lesions, hypertrophic cardiomyopathies). Finally, in a certain number of cases, the observed abnormalities could only be seen as presumptive evidence (mitral prolapse, sequelae of myocarditis, or the presence of toxic agents). Failure to establish a precise diagnosis at autopsy occurred in only 22 cases (11%), however, amphetamine drug presence was discovered in 7 of these cases. Approximately one-half of the group studied revealed atheromatous coronary artery lesions (29% of cases) or congenital lesions (17.5%) especially involving the origin of the left coronary artery. These were followed in frequency by the hypertrophic cardiomyopathies. Mitral valve prolapse and WPW syndrome were rarely encountered. Extracardiac causes included rupture of the aorta (4.5%) and cerebral vascular accidents (5%).

[Biventricular thrombosis in nephrotic syndrome with hypercoagulability and hypereosinophilia]. / Thrombus biventriculaires au cours d'un syndrome néphrotique avec hypercoagulabilité et hyperéosinophilie.

A case of double right and left intraventricular thrombosis diagnosed by 2D echocardiography is reported in a 20 year old man with nephrotic syndrome with eosinophilia and hypercoagulability, admitted as an emergency for a staphylococcal septicaemia in shock and anuria. Anticoagulation with heparin did not prevent two episodes of pulmonary embolism. Complete dissolution of the thrombi was obtained by peripheral administration of fibrinolytic therapy (urokinase and plasminogen). The authors discuss the differential diagnosis of echocardiographic appearances of biventricular masses and possible causes of these thrombi are suggested.

Two-dimensional echocardiographic recognition of aortic valve ring abscess.

2D-echocardiography was performed in 42 consecutive patients with suspected aortic endocarditis who subsequently underwent surgery. On surgery, 12 patients had perivalvular aortic abscesses: in the posterior part of the ring (7) with extension to the aorto-mitral fibrous trigone or pseudo-aneurysm of the aortic wall; in the anterior part of the ring (3), with extension toward the interventricular septum; or with near complete aorto-left ventricular disruption (2). Perivalvular abscess was seen on 2D-echo in 8 patients: echo-free cavity located in the aortic ring, beyond the sigmoid valvulae and sometimes containing necrotic material. In 4 patients, the abscess was not diagnosed on 2D-echo; 2 had small, localized abscesses but the remaining 2 had large abscesses developed around previously implanted mechanical prostheses, which considerably impeded echographic examination. One additional patient with acute aortic regurgitation and fever had an image of posterior abscess, but on surgery, the posterior wall of the aorta appeared inflammatory and oedematous without perivalvular abscess. Accurate topographic diagnosis was made in 6 of the 8 patients, while in 2 the abscess was located more to the left than considered on 2D-echo. Generally, 2D-echo tended to underestimate the importance and extension of the lesions. It is concluded that 2D-echo is helpful to diagnose perivalvular aortic infection.

[Retrospective study of the role of systematic coronarography in patients with heart valve diseases]. / Etude rétrospective du rôle de la coronarographie systématique chez les patients valvulaires.

The aim of this study was to assess retrospectively the valve of routine coronary angiography in the investigation of patients with valvular heart disease. Between 1978 and 1981, 598 patients over 40 years old underwent left heart catheterisation with routine coronary angiography. In the group with a medical history of angina or infarction (N = 149), there were 49 cases (33%) of severe coronary artery disease (greater than or equal to 70%) and 17 cases of moderate coronary artery disease (11%); of the 49 patients with severe lesions, 2 died after catheterisation, 8 were considered to have too high an operative risk because of their coronary disease and 19 were operated. Valve replacement was associated with a procedure for myocardial revascularisation in 15 cases. In the group without angina (N = 449), severe coronary lesions were much less common (3.6%) and only 5.1% had moderate coronary disease. Severe coronary lesions were found more frequently in certain sub-groups: Stage IV dyspnoea (9%), patients over 65 years of age (11.5%), and coronary calcification (24%). Of the 39 patients without angina and over 50% narrowing on coronary angiography, 17 underwent isolated valve surgery, and 9 underwent combined valvular and coronary surgery (2% of catheterised patients without angina; 3.5% of patients operated without angina. These results show that routine coronary angiography is fully justified in patients with valvular heart disease and a history of angina as vital information is obtained in a high proportion of cases.(ABSTRACT TRUNCATED AT 250 WORDS)