Management of heart failure in the elderly: recommendations from the French Society of Cardiology (SFC) and the French Society of Gerontology and Geriatrics (SFGG).

Heart failure, a frequent disease in the elderly, has a pejorative prognosis. Clinical diagnosis is complicated by atypical or difficult-to-interpret symptoms and by the concomitant presence of other diseases, particularly cognitive impairment, neurological disorders and diseases of the musculoskeletal system. Among the additional investigations, echocardiography remains underused. Impairment of diastolic left ventricular function is frequent. The usual laboratory tests must include calculation of the creatinine clearance, which is indispensable for dosage adjustment of certain drugs (ACE inhibitors, digoxin, spironolactone). The value of plasma natriuretic peptide assays as diagnostic tools has not been determined in elderly or very elderly populations and the plasma B-type natriuretic peptide increases with age. Comprehensive geriatric assessment is essential in order to screen for concomitant diseases and determine the patient's degree of dependence. The general objectives of treatment remain applicable to the elderly subject: improvement in the quality of life, reduction of mortality and the number and duration of hospitalisations, and slowing disease progression. In the frail elderly subject, symptom alleviation is to be the primary objective. In the absence of specific studies on elderly or very elderly subjects, most of the recommendations have been extrapolated from the data based on the evidence generated in younger populations. The dietary rules are to be more flexible than those used for younger subjects, particularly in order to prevent the risk of denutrition induced by strict salt-free diets. Special precautions for the use of heart failure drugs are due to comorbidities and the pharmacokinetic and pharmacodynamic changes related to aging. Drugs dosage increase is to be cautious and carefully monitored for adverse reactions. The therapeutic programmes in which multidisciplinary teams are involved reduce the number and duration of hospitalisations and the costs generated by the disease.

[Deep cerebral venous thrombosis]. / Les thromboses veineuses cérébrales profondes.

Deep cerebral venous system thrombosis is uncommon and is usually encountered in children, generally in the neonatal period. In adults, this pathology is even more exceptional. We report two cases in adults. Deep cerebral venous system thrombosis mainly affects women taking oral contraception. The most common clinical pattern combines headaches and confusion. A comatose state is rather exceptional. This pathology, formerly considered to have poor prognosis, has benefited from diagnostic and therapeutic progress. Favorable outcome has been achieved in several recent cases, as one of ours, without after-effects. Diagnosis, often suggested by the CT-scan, is based on MRI associated with MRA. Thrombus formation is easily diagnosed by MRI at the subacute stage, but far less easily at the acute and chronic stages as the low signal is identical to the normal flow void. MRA, in phase contrast or time of flight sequences, is highly interesting at the acute phase. In case of doubt, an angiography can be applied. Therapy is based on heparin. The contribution of local infusion of thrombolytic agents, recently used with success, remains to be determined.

Temporal artery involvement revealing AL amyloidosis and IgD monoclonal gammopathy.

We report a patient who presented with clinical symptoms suggesting giant cell arteritis. A diagnosis of AL amyloidosis was made on temporal artery biopsy. Temporal artery involvement is unusual in AL amyloidosis, but its frequency may be underestimated. Another uncommon finding was the presence of an IgD monoclonal gammopathy without diagnostic features of multiple myeloma.

Colonoscopy in the elderly: a study of 200 cases.

OBJECTIVES: To evaluate tolerance and diagnostic yield of colonoscopy in elderly patients. METHODS: We studied retrospectively 200 consecutive colonoscopies performed in patients older than 80 years (mean age: 83.5 +/- 3.1). We analyzed the following factors: indication, type and tolerance of the preparation, analgesia, tolerance of the procedure, information provided by the examination and therapeutic consequences. RESULTS: The indications were: anaemia in 81 cases, change in bowel habits in 58 cases, rectal bleeding in 26 cases and others in 35 cases. Preparation (4.2 +/- 1.3 L Polyethylene-glycol) was good 150 times (75%), moderate 27 times and poor 23 times. It was tolerated well 122 times (61%) and poorly 78 times (39%). Sixty-six colonoscopies were performed without any analgesia, diazanalgesia was used in 108 cases, general anesthesia in 8 and diazepam and/or antispasmodics in 18. Tolerance of colonoscopy was good in 140 cases (70%), moderate in 37 cases and poor in 23 cases. Tolerance was better with analgesia than without (p < 0.001). The caecum was reached in 167 cases (83.5%). Colonoscopy was normal in 68 cases (34%). The lesions discovered were: 40 polyps larger than 10 mm, 41 diverticulosis, 29 cancers, 7 ischaemic colitis, 5 angiodysplasias, 5 sigmoiditis, 3 villous adenomas, 1 Bothriocephalus and 1 thermometric ulceration. A lesion responsible for the symptoms was diagnosed in 80 cases (40%). Diagnostic yield was better when indication was anaemia (52%) than change in bowel habits (24%) (p < 0.001). The lesions were treated endoscopically in 41 cases (38 polypectomies, 3 electrocoagulations) and surgically in 22 cases. Colonoscopy as well as its preparation were well tolerated in 93 cases (46.5%). CONCLUSION: In a selected elderly population, colonoscopy was better tolerated with analgesia; large bowel preparation was often difficult. The diagnostic yield was relatively good. A multicentric prospective study is underway in order to determine the predictive criterias allowing an improvement of colonoscopic yield in the elderly.

[Measurement by isotope study of the cardiac output in the elderly]. / Mesure par étude isotopique du débit cardiaque chez le vieillard.

Cardiac output and haemodynamic volumetric values (stroke volume, stroke index, left ventricular end-diastolic volume, blood volume, mean corpuscular volume and packed red cell volume) were measured in a population of 69 very old subjects (80 to 102 years) whose heart was regarded as normal on the basis of criteria determined, by radiocardiography and radionuclide ventriculography. These harmless and non-invasive techniques provided reference values in subjects of a seldom explored age group. Altogether, these values were lower than those of younger adults, and they decreased with age. Their reliability is due to the fact that they were obtained by true measurement and not by extrapolation of results observed in adults.

[Self-poisoning with propafenone. Apropos of a case]. / Intoxication volontaire par la propafénone. A propos d'un cas.

The authors report one case of voluntary intoxication induced with 2,700 mg of propafenone in a 23 y.o. man presenting a right ventricle dysplasia. The intoxication is expressed by a blood pressure drop with convulsions and conduction disorders: 1st degree A-V block and transient right bundle branch block. The serum levels of propafenone, initially at 3,185 ng/ml reach therapeutic levels in 8 hours.

[Comparative pharmacokinetics of piperacillin in young and elderly subjects]. / Pharmacocinétique comparative de la pipéracilline chez le sujet jeune et le sujet âgé.

One single 4 g dose of piperacillin was administered by intravenous infusion over 30 min to 15 patients aged from 66 to 90 years (mean +/- s.e.m.: 79.8 +/- 2.0 years); the patients mean weight was 53 +/- 4 kg. Fifteen samples of blood were withdrawn from each subject. Plasma piperacillin levels were measured by high performance liquid chromatography with detection in ultraviolet light at 214 nm. Mean plasma piperacillin concentrations in elderly subjects, measured 0.5, 2 and 12 h after dosing, were 168.5 +/- 15.7, 79.9 +/- 11.5 and 1.72 +/- 0.69 microgram.ml-1, as against 146.8 +/- 10.6, 35.5 +/- 3.9 and 0.212 +/- 0.040 microgram.ml-1 in healthy young adults. Plasma piperacillin concentrations versus time curves obtained after the infusion was discontinued were bi-exponential, with half-lives T1/2 (lambda 1) and T1/2 (lambda 2) of 0.65 +/- 0.11 and 1.72 +/- 0.09 h respectively; the corresponding figures in young adults were 0.59 +/- 0.03 and 1.81 +/- 0.13 h respectively). In elderly subjects the mean total clearance of piperacillin (ClT = 2.90 +/- 0.25 ml.min-1.kg-1) was reduced by 15% (NS) and the volume of distribution during steady state (Vdss = 0.337 +/- 0.027 L.kg-1) was increased by 43% (P less than 0.001). As a result, the mean time of piperacillin stay in the body (MRS = Vdss/Cl) was practically doubled in elderly subjects (2.09 +/- 0.15 h as against 1.15 +/- 0.04 h in young adults (P less than 0.01).

Importance of atrial electrophysiology in the work-up of cerebral ischemic attacks.

Recent data suggest that a large proportion of ischemic strokes are due to embolic phenomena from the heart. Atrial fibrillation appears to be one of the principal causes of embolization. If electrophysiologic parameters are considered as determining factors, the existence of atrial hypervulnerability in patients with embolic strokes is significant, when arrhythmia has been excluded as an etiology. This study suggests that an aggressive approach to early diagnosis and management through electrophysiologic studies might aid in preventing future neurologic attacks.

[Pericarditis and pulmonary embolism. A difficult differential diagnosis and a confusing association]. / Péricardite et embolie pulmonaire. Un diagnostic différentiel difficile, une association déroutante.

The association of pericarditis and pulmonary embolism may be the source of diagnostic error and delay in the administration of anticoagulant therapy. Two cases are reported. Pericarditis occurred late in patients with severe, chronic pulmonary embolism with electrocardiographic changes of acute cor pulmonale. Two physiopathological mechanisms for this association have been proposed. The first, haemodynamic, suggests friction between the pericardium and distended right ventricle and pulmonary artery. The second, an immunological hypothesis, compares the association of pericarditis and pulmonary embolism to that of the Dressler syndrome after myocardial infarction. This assimilation would imply the constitution of an anatomical pulmonary infarction. It is not justifiable to accept this pathogenesis on the evidence of transient pulmonary opacities resulting from intra-alveolar haemorrhage or of linear opacities of pulmonary atelectasis secondary to hypocapnic pneumoconstriction which are radiological signs of anatomo-physiological stages of pre-infarction.

Long-term prevention of vagal atrial arrhythmias by atrial pacing at 90/minute: experience with 6 cases.

Six patients (5 men, 1 woman) with a history ranging from 3-16 years of resistant vagal atrial arrhythmias were treated by atrial pacing at a rate of 90/Min. These patients have been followed up for an average of 5.5 years (range 2-11 years) with favorable results. The arrhythmias were characterized by daily or weekly attacks of typical atrial flutter and atrial fibrillation occurring mainly or exclusively at night, at rest, or in the digestive periods in otherwise normal hearts of middle-aged patients (first attack between 25 and 54, mean 40). The arrhythmias were resistant to quinidine, and were usually aggravated by digitalis, beta-blockers and verapamil. Amiodarone is usually the only effective drug in this syndrome, but was not used before pacing in the 2 first cases, and was ineffective in the other 4 cases. Electrophysiologic studies confirmed the absence of sick sinus syndrome, and the close relationship between relative bradycardia and the onset of the arrhythmia. Atrial pacing alone totally controlled the arrhythmia in 1 patient; amiodarone was used in conjunction with pacing in 3 patients. In 1 patient the improvement was clear but incomplete, and in 1 patient permanent atrial fibrillation occurred shortly after pacemaker implantation.

[Cryptic miliary tuberculosis. Two case-reports (author's transl)]. / Les tuberculoses miliaires cryptiques. A propos de deux observations.

The term cryptic miliary tuberculosis designates a particular form of hematogenous tuberculosis in which the usual diagnostic criteria, especially the roentgenographic ones, are lacking. Two cases are reported. Initial clinical manifestations were prolonged fever, poor general condition, low blood pressure, low serum sodium, mild hepatic biological disorders, and myocarditis. No other radiological or biological features, suggestive of tuberculosis were found. In the first patient, the various visceral tuberculous localizations occurred under specific treatment, although the latter was otherwise effective. In the second patient, they were identified by pathological examination. The incidence of these occult forms of tuberculosis, where diagnosis is often established too late, and sometimes only postmortem, is not negligible. This possibility must be borne in mind in severe infectious conditions without obvious etiology, particularly when the following features are present : inadequate secretion of ADH, which often indicates latent encephalitic and meningitic involvement where CSF anomalies may be incomplete or lacking ; leucopenia or pancytopenia ; biological hepatic anomalies ; exceptionally, such as in the two cases described, cardiac involvement. Among diagnostic procedures, liver biopsy is of the utmost importance. Mere diagnostic presumption is sufficient to warrant initiation of antituberculous therapy. This ensures survival and, paradoxically, allows delayed overt clinical manifestations to develop.

[Cerebrovascular accident presenting as continuous partial epilepsy (author's transl)]. / Epilepsie partielle continue révélatrice d'un ramollissement cérébral.

Epileptic seizures due to cerebrovascular accidents are relative rare and only very exceptionally occur in the form of Kojewnikoff's continuous partial epilepsy. A 75-year-old man developed myoclonic spasms, limited to the face, following a left posterior cerebral ischaemic accident. The authors discuss the relationship between epilepsy and cerebrovascular accidents, and differentiate post-ischaemic epilepsy of deferred onset from epilepsy occurring simultaneously with a vascular accident, the latter sometimes presenting as fits. The relationship between myoclonic spasms and Kojewnikoff's continuous partial epilepsy are also discussed.