A multifactorial health risk questionnaire.

OBJECTIVE: to assess the relations between cardiovascular risk factors and psychological or socio-economic status. METHODS: We used a self-questionnaire including data upon usual risk factors, anxiety, depression, behavioural pattern, somatic manifestations, life style, incomes and work-related stress. We gathered 955 people, mainly attending an occupational health examination, filling anonymously the same restricted questionnaire (83 questions). RESULTS: Non-working people represented only 4.4 per cent of the study group and included mainly retired people. They differed significantly from wage earners by a higher level of cardiovascular risk and depression, respectively 15.8 (s.d. 11.3) versus 7.8 (6.7) and 5.6 (3.5) versus 3.9 (2.8). These differences can be related to older age of this group. Among working people, 30 per cent felt job-insecurity; they differed significantly from working people by a higher level of anxiety, 8.9 (3.7) versus 7.5 (3.3). There was no difference concerning the absolute cardiovascular risk or the behavioural pattern. A comprehensive self questionnaire is proposed.

Usefulness of pulmonary regurgitation Doppler tracings in predicting in-hospital and long-term outcome in patients with inferior wall acute myocardial infarction.

Right ventricular (RV) involvement is frequent during inferior wall acute myocardial infarction (AMI) and has been reported as a risk factor for in-hospital morbidity and mortality. The objectives of the present study were: (1) to evaluate in-hospital events in patients with and without RV involvement as diagnosed by abnormal flow characteristics derived from pulmonary regurgitation (PR) analysis (pressure half-time of PR, PHT(PR) < or = 150 ms and the lowest mid-diastolic to peak early diastolic velocity ratio, Vmin/Vmax < or = 0.5); and (2) to determine the influence of RV involvement in complications at long-term follow-up. Among 126 consecutively admitted patients with inferior wall AMI (mean age, 58 +/- 13 years), 101 had PR. We determined the prognostic significance of in-hospital and long-term events for the following variables: age > or = 65 years, ST-segment elevation > or = 1 mm in lead V4R, RV dilation, PHT of PR < or = 150 ms and Vmin/Vmax < or = 0.5, thrombolytic therapy, 3-vessel disease, and diabetes mellitus. We found that the PR derived Doppler index (PHT of PR < or = 150 ms and Vmin/Vmax < or = 0.5) was the only predictor of overall in-hospital clinical events (hazards ratio, 2.7, 95% confidence interval, 1.2 to 6.1, p = 0.016). At long-term follow-up (mean: 20 +/- 12 months, range 12 to 69), event-free survival analysis showed that age > or = 65 years was the only predictor of any event (relative risk, 3.7, 95% confidence interval, 2.1 to 6.3, p < 0.0001). Thus, RV involvement diagnosed with the use of PR flow-derived variables is an accurate and independent predictor of in-hospital complications. However, RV involvement does not influence long-term prognosis.

Is dobutamine stress echocardiography useful for noninvasive differentiation of ischemic from idiopathic dilated cardiomyopathy?

Dobutamine stress echocardiography was performed in 56 consecutive patients, mean age: sixty-two +/- twelve years. Twenty-two patients had an idiopathic dilated cardiomyopathy (group 1) and 34 had angiographically proven ischemic dilated cardiomyopathy (group 2). Wall motion score index and left ventricular ejection fraction were determined at baseline, 5 micrograms/kg/min, peak, and ten minutes after stepwise dobutamine infusion. Worsening or no change in global wall motion score was observed in 9 group 2 patients (26%) and 1 group 1 patient (5%, P = .07). No significant difference was observed with regard to wall motion score index decrease between baseline and peak dose. Left ventricular ejection fraction increase during dobutamine infusion was comparable in both groups. Thus, an ischemic response was observed more often in the coronary artery disease group, yielding a good specificity and positive predictive value although sensitivity was low. However, left ventricular function improvement did not help to discriminate patients with or without significant CAD.

[Clinical, echocardiographic and Doppler outcome in ischemic right ventricular dysfunction associated with inferior wall infarction]. / Evolution clinique, échocardiographique et Doppler de la dysfonction ischémique ventriculaire droite associée à un infarctus inférieur.

Right ventricular involvement during inferior wall myocardial infarction does not seem to alter long-term clinical prognosis but its specific outcome has not been clearly studied. We have previously demonstrated that pulmonary regurgitant (PR) flow tracings doppler analysis allows the accurate diagnosis of RV involvement, especially when the pressure half-time of PR was < or = 150 ms and the ratio of the minimal velocity to the maximal velocity was < or = 0.5. We studied 40 patients with acute inferior wall myocardial infarction and with PR flow. Doppler echocardiography was obtained during the first day, before discharge (early control) and between 12 and 24 months follow-up (late control). Among 22 patients with RV involvement defined with PR-derived doppler parameters (RVIPR). 8 had right ventricular enlargement and/or wall motion abnormalities, observed in 6 cases at early control and in 4 at late control. Doppler analysis showed remnant RVIPR parameters in 9 patients at early control and 8 among these at late contorl, with no relation with pulmonary artery pressure or other echocardiographic parameters. No clinical, angiographic or therapeutic data predicted these distinct echocardiographic and doppler patterns and the long-term prognosis was not different. At late control, among 12 RVIPR patients which PR-derived doppler parameters were normal at early control, two patients had still RVIPR pattern at late control and described ischemic recurrence. PR flow doppler analysis is a useful tool for diagnosis and outcome evaluation of RV involvement and shows a remnant diastolic dysfunction in half of the patients with acute RV involvement.

[Dobutamine stress echocardiography; a monocentric experience on 600 consecutive patients. Effect of age]. / Echocardiographie sous dobutamine; expérience monocentrique portant sur 600 patients consécutifs. Influence de l'âge.

The increasing indications of dobutamine stress echo in the investigation of myocardial ischaemia, viability and evaluation of the prognosis of coronary artery disease has made this technique a tool of everyday clinical practice. The authors reviewed the results of 600 investigations in consecutive unselected including patients aged over 75. No significant difference was observed with respect to the causes of interruption of the test between patients aged less than 75 (521 patients) and those older than 75 (79 patients). Attaining the target theoretical maximal heart rate was the commonest reason for stopping the test (47 and 48% respectively). Ventricular arrhythmias were not more common (12 and 10% respectively). Twelve cases of ventricular tachycardia were observed, 8 of which were non-sustained; 9 led to interruption of the test. No cases of ventricular fibrillation were observed. A previous history of cardiac arrhythmias was not associated with a higher frequency of arrhythmia during the test (8% in those with a previous history, 4% in those patients without). Supraventricular arrhythmias were significantly more common in patients over 75 years of age (15 versus 8%, p = 0.046). Dobutamine stress echocardiography' is feasible in a population of unselected patients, including those over 75. Therefore, age does not represent a limitation to the extension of this investigation.

Hemodynamic criteria for diagnosis of right ventricular ischemia associated with inferior wall left ventricular acute myocardial infarction.

To test the diagnostic value of different hemodynamic indexes for the diagnosis of acute right ventricular (RV) ischemic dysfunction, we studied 2 groups of consecutive patients admitted for an acute left ventricular inferior wall myocardial infarction: 51 patients with (group 1) and 32 patients without (group 2) RV ischemia as determined by coronary angiography. In both groups, we analyzed by right-sided cardiac catheterization right-sided heart pressures, pulmonary capillary wedge pressure, and cardiac index. We also calculated pressure ratios (mean right atrial pressure or RV end-diastolic over pulmonary capillary wedge pressures), pulmonary vascular resistance, and RV stroke work index. We found significant differences (p < 0.01) between the 2 groups when comparing mean right atrial pressure, RV end-diastolic pressure, ratio of these 2 pressures over pulmonary capillary wedge pressure, RV stroke work index, and right atrial and RV pressure waveforms. The best combined sensitivity, specificity, positive predictive value, negative predictive value, and diagnostic accuracy were found for the right atrial M or W waveform pattern, isolated or combined with a disproportionate elevation of RV end-diastolic over pulmonary capillary wedge pressures (respectively, 92%, 94%, 90%, 87%, and 89%). Volume loading was performed in 27 patients (18 with and 9 without RV ischemia). Right heart pressures and RV stroke work index increased significantly and similarly in both groups. Cardiac index increased significantly only in patients without RV ischemia (p = 0.02). However, volume loading did not significantly modify the diagnostic value of the different hemodynamic criteria studied.(ABSTRACT TRUNCATED AT 250 WORDS)

[Morphological study by transesophageal echocardiography and clinical aspects of ruptured chordae tendineae in the elderly]. / Etude morphologique par échocardiographie transoesophagienne et aspects cliniques de la rupture de cordages mitral chez le sujet âgé.

Ruptured mitral chordae tendinae is a classical complication of myxomatous mitral valves or Barlow's syndrome. This complication is controversial in non-myxomatous mitral valve. Of 91 consecutive patients with mitral valve prolapse examined over an 18 months period by transthoracic and transesophageal echocardiography, 42 (18 women and 24 men) with an average age of 76 +/- 8 years (60-93 years) had ruptured mitral chordae tendinae. The thickness of the anterior mitral leaflet measured at the distal third of the valve by transesophageal echocardiography enabled the identification of two groups of patients; group I: > 3 mm (24 patients), average 4.8 +/- 0.8 mm and group II: < or = 3 mm (18 patients), average 2.6 +/- 0.3 mm. The diameter of the mitral ring and left atrium, the length of the anterior mitral leaflet, the left ventricular end diastolic dimensions and fractional shortening, were measured by transthoracic 2D echocardiography (mitral ring) and M mode (other parameters). Ruptured chordae were detected in only 13 cases (31%) by transthoracic echocardiography; 38% were asymptomatic and a chance finding at transesophageal echocardiography. No significant difference was observed between the two groups with respect to age, gender presence of hypertension, dimensions of the cardiac chambers, fractional shortening or localisation of the prolapse related to the ruptured chordae. Fifty-eight per cent of patients in group I were in NYHA functional classes 3-4 as compared to 16% in group II (p < 0.02). The size of the left atrium was significantly greater in group I, 51 +/- 8 mm vs 38 +/- 7 mm (p < 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)

Relations between Doppler tracings of pulmonary regurgitation and invasive hemodynamics in acute right ventricular infarction complicating inferior wall left ventricular infarction.

To test the hypothesis that flow characteristics from pulmonary regurgitation (PR) can predict right ventricular (RV) involvement in patients with inferior wall acute myocardial infarction, we prospectively recorded continuous-wave Doppler tracings and right-sided cardiac hemodynamics in 48 consecutive patients with inferior wall acute myocardial infarction and PR. Right heart hemodynamics enabled the identification of 29 patients with (group 1) and 19 without (group 2) RV involvement. In patients with RV involvement, the pulmonary regurgitant flow pattern was characterized by a rapid rise in flow velocity to a peak level followed by an abrupt deceleration in mid-diastole, whereas in patients without RV involvement, the deceleration in mid-diastole was gradual. The pressure half-time of PR (PHTPR) and the lowest mid-diastolic to peak early diastolic velocity ratio were significantly lower in group 1 than in group 2 (91 +/- 31 vs 214 +/- 57 ms [p < 0.001], 0.35 +/- 0.08 vs 0.59 +/- 0.13 [p < 0.001], respectively). The best diagnostic accuracy (95%) was obtained with cut-off values of PHTPR < or = 150 ms and the lowest mid-diastolic to peak early diastolic velocity ratio < or = 0.5: sensitivity 100%, specificity 89%, positive predictive value 94%, and negative predictive value 100%. Using multiple logistic regression analysis, we found that PHTPR was the strongest predictor of RV involvement. Thus, these parameters, derived from pulmonary regurgitant tracings, are useful in the noninvasive bedside diagnosis of RV infarction.

Radioisotopic pacemaker: long-term clinical results.

In order to prolong the service life of the generator, the isotopic pacemakers, powered by Pu238, have been developed and implanted since 1970. We report the follow-up of 325 patients (mean age 39 +/- 18 years) implanted with an isotopic pulse generator (Medtronic 9000/9090) between April 1970 and July 1982. The mean follow-up was 12 years (range 6 days to 18.5 years). The generator was highly reliable; the mean value of pacing rate between implantation and last follow-up decreased significantly but no more than 1 beat/min (72.7 vs 71.8 beats/min; P < 0.001) and the pulse width did not change significantly. The actuarial survival of the device was 97% at 18.5 years. During the follow-up period, 122 reoperations were performed in 85 patients: 88 explanations of the entire pacing system and 34 modifications of the lead system. Lead dysfunction accounted for 68% of the 122 reoperations, generator failure for 6%, and miscellaneous reasons for 26%. However, 72% of patients remain free of intervention during the follow-up period and 61 patients (20%) died during this period. Most deaths (52%) were of nonsudden cardiovascular origin, 17% were related to cancer, and 13% to sudden death. After 5, 10, and 18.5 years, 94%, 89%, and 73% of the patients were alive, respectively. No side effect could be attributed to the radioisotope. We conclude that this isotopic pacemaker demonstrated its reliability for long-term cardiac pacing.

[Segmental myocarditis in Churg-Strauss syndrome. Review of the literature apropos of a case]. / Myocardite segmentaire au cours du syndrome de Churg et Strauss. Revue de la littérature à propos d'un cas.

We describe a 25-year old man in whom segmental myocarditis and pericarditis was diagnosed using two-dimensional echocardiography. Churg-Strauss syndrome was suspected in the presence of asthma and evidence of hypereosinophilia. Early therapy with oral prednisone led to resolution of pericarditis but septal hypokinesia was still present after 4 years. The pathophysiology of segmental myocarditis in the Churg Strauss syndrome is discussed.

Analysis of emergency department interpretation of electrocardiograms.

The objective of the study was to determine the concordance of emergency physicians' and cardiologists' interpretations of emergency department (ED) electrocardiograms (ECG), to evaluate the impact of ECG misinterpretation on patient management, and to determine error rates as a function of the level of physician training and the specific ECG diagnoses. ECG interpretations were registered prospectively using a programmed-response data sheet. A second blinded interpretation by a staff cardiologist was assumed to be correct. Only ECG discrepancies with potential or probable clinical importance were considered as errors. The ED management of patients with ECG misinterpretations was reviewed by the investigators. The study was performed at an urban university hospital using 300 consecutive ED ECGs. The analysis found 154 errors of interpretation of which nine had probable clinical significance, and 56 had indeterminant significance. The concordance was weak at 0.69 (Kappa = 0.32, weighted Kappa = 0.30) with a significant discordance (McNemar Chi 2:P < 0.05). Error rates did not differ significantly between the diverse categories of physicians. In two cases, interpretation errors impacted patient management decisions but not patient outcomes. The most frequent errors involved repolarization abnormalities, ventricular hypertrophy and hemi-blocks. While discordance was significant, errors in ECG interpretation rarely impacted patient management. Prospective evaluation of ECG interpretation may be a useful means of gauging physician skills. It can also serve to focus educational activities on problem areas in electrocardiography.

Aortic dissection and cardiovascular syphilis: report of an observation with transesophageal echocardiography and anatomopathologic findings.

We report the case of a man who had thoracic pain and stroke. Transesophageal echocardiography enabled us to diagnose an intramural hematoma and a saccular aneurysm of the thoracic aorta before he died. Autopsy showed lesions compatible with syphilitic aortitis in the aortic wall. Transesophageal echocardiography and anatomopathologic findings are correlated, and the role of syphilis as a causal factor is discussed.

[Value of transesophageal echocardiography in the cardiovascular assessment of an ischemic cerebral accident of suspected embolic origin]. / Intérêt de l'échocardiographie transoesophagienne dans le bilan cardio-vasculaire d'un accident ischémique cérébral présumé d'origine embolique.

Transoesophageal echocardiography (TOE) is a new modality of cardiac investigation allowing examination of cardiac structures and anomalies previously inaccessible to ultrasound. TOE is performed under local anaesthesia after fasting the subject for more than 4 hours and after premedication when the patient is admitted to hospital. In the assessment of an ischaemic cerebral vascular accident, TOE may reveal potential sources of emboli such as intracavitary thrombi and tumours (left atrium and left atrial appendage), atherosclerosis of the aortic arch, vegetations. Certain indirect causes may also be more clearly identified: aneurysm of the interatrial septum, patent foramen ovale for which the causal relationship is more difficult to establish. Intra-atrial blood stasis ("spontaneous echo contrast") is perfectly analysed in the form of intra-atrial "smoke" observed in the presence of atrial dilatation, particularly in the presence of atrial fibrillation and mitral valve obstruction (mitral stenosis, valve prosthesis). The indication for TOE in this context is currently under evaluation, particularly in young patients. It is routinely indicated in patients with known heart disease when peripheral embolism is suspected, looking for intracavitary thrombosis, generally not seen on transthoracic echocardiography.

[Arrhythmia and syndrome of obstructive sleep apnea in adults]. / Arythmies et syndrome d'apnées obstructives du sommeil de l'adulte.

Many nocturnal cardiac arrhythmias and conduction defects have been reported in the adult sleep apnoea syndrome. The most original is the great variability of the heart rate which is cyclical and related to the apnoeic episodes, and easily differentiated from simple respiratory sinus arrhythmia. It is characterised by an initial bradycardia followed by rebound tachycardia. The bradycardia is vagally dependent (inhibited by atropine) probably secondary to carotid chemoreceptor stimulation by the hypoxaemia. The tachycardia is mainly attributed to the cessation of vagal hypertonicity although catecholamine stimulation has been suggested. The origin of these changes is purely functional, regressing with treatment of apnoea (waking, tracheotomy), the maintenance of arterial oxygen concentrations with oxygen therapy and parasympathetic blockade (atropine). The intensity of the phenomenon is related to the degree of arterial desaturation, which is itself related to basal arterial saturation (SaO2) and the duration of the apnoeas. Prolonged systole due to paroxysmal sino-atrial or atrioventricular block may be observed at night in these patients. The influence of vagal overactivity is confirmed (suppression of vagotomy) with no organic pathology (diurnal absence, tracheotomy, normal electrophysiological testing) in favour of a relationship with apnoea. Though less common than conduction abnormalities, atrial arrhythmias (extrasystoles, flutter, fibrillation) are also possible complications of sleep apnoea. The absence of an organic substrate is indicated by their regression post-tracheotomy and the efficacy of atropine (again in favour of a vagally-induced mechanism). Finally, nocturnal ventricular hyper-excitabilty is sometimes observed, the probable mechanism being the association of severe hypoxaemias (SaO2 < 60%) and the increased sympathetic tone at the end of the apnoea.(ABSTRACT TRUNCATED AT 250 WORDS)

[Incidental finding of an isolated thrombus in the left atrium in a young woman with sinus rhythm 5 years after cerebral ischemic accident]. / Découverte fortuite d'un thrombus isolé de l'auricule gauche chez une femme jeune en rythme sinusal 5 ans après un accident ischémique cérébral.

The authors report the case of a 40 year old woman who had an ischemic stroke. The initial investigation including a complete blood clotting analysis, failed to demonstrate the cause. Five years later, the investigations were completed systematically by transesophageal echocardiography which demonstrated an isolated thrombus localised in the left atrial appendage though the localisation heart was in sinus rhythm and morphologically normal. This case illustrates in the diagnostic yield of transesophageal echocardiography in the investigation of systemic embolism in young patients who have had a cerebral ischemic event of unknown cause, even in the absence of predisposing cardiac cause.

[Early constrictive pericarditis after coronary revascularization. Apropos of a case]. / Péricardite constrictive précoce après revascularisation coronaire. A propos d'un cas.

The authors report a case of severe constrictive pericarditis occurring 6 weeks after coronary bypass surgery and in the absence of any other predisposing factor. The diagnosis was confirmed by CT scan and cardiac catheterisation which showed signs of a diastole. The patient died despite early surgical reoperation because of the severity of the pericardial fibrosis.

[Does ambulatory determination of blood pressure allow the measurement of white coat effect?]. / L'enregistrement ambulatoire de la pression artérielle permet-il de mesurer l'effet blouse blanche?

UNLABELLED: The aim was to find an objective indicator in order to evaluate white coat effect (WE). The first hour average values after placing an ambulatory blood pressure recorder (15 mn intervals) were compared to those of the 4 following hours of diurnal activity. A first hour systolic arterial blood pressure (SBP 1H) increase of 10 mmHg or more was considered as an ambulatory WE positive (AWE+) and was compared to clinical WE (CWE). CWE+ was observed in 78 pts and AWE+ in 72 among a group of 172 unselected pts referred for hypertension. RESULTS: the correlation between AWE and CWE is weak (r = 0.49) but significant (p < 0.001). There was no difference between the two groups in age, sex, clinical blood pressure, heart rate or ambulatory BP after the first hour (table). There was a significant difference in SBP between the 2 groups (p < 0.001) during the first hour only. [table: see text] CONCLUSION: Ambulatory blood pressure recording is able to recognize and evaluate the white coat effect. We suggest to consider independently the first hour of each recording and to compare it with the mean pressure measured during the period of diurnal activity.