Comparison of HIV-Infected and Noninfected Patients Undergoing Bariatric Surgery: The ObeVIH Study.

OBJECTIVE: The aim of this study was to compare clinical characteristics and adipose/liver tissue histology analysis in HIV-infected and HIV-uninfected subjects undergoing bariatric surgery. DESIGN: This was a cross-sectional study of HIV-infected subjects undergoing single-port sleeve gastrectomy with prospective enrolment and frequency age (±5 years), sex, and body mass index (BMI, ± 5 kg/m2) matched on HIV-uninfected subjects. METHODS: This study was conducted at a single clinical site at Pitié-Salpêtrière hospital-Paris-France comprising 19 HIV-uninfected and 21 HIV-infected subjects with plasma VL < 20 copies/mL, all with a BMI > 40 kg/m2 or >35 kg/m2 with comorbidities. Histology of subcutaneous and visceral abdominal adipose tissue (SCAT/VAT) and liver biopsies was collected during single-port sleeve gastrectomy. Outcomes included anthropometric characteristics, comorbidities, cardiovascular parameters, adipose tissue, and liver histology. RESULTS: The age of HIV-infected participants was (median, interquartile range IQR) 48 y (42-51), with 76.2% females, a BMI of 41.4 kg/m2 (37.3-44.4), an antiretroviral duration of 16 y (8-21), current integrase strand transfer inhibitor (INSTI)-based regimen in 15 participants and non-INSTI regimen in 6 participants, and a CD4 count of 864/mm3 (560-1066). The age of controls was 43 y (37-51), with 78.9% females and a BMI of 39.2 kg/m2 (36.3-42.6). Anthropometric characteristics, comorbidities, and cardiovascular parameters did not differ according to HIV status and INSTI treatment. The number of macrophage crown-like structures in SCAT was lower in INSTI-treated participants than in HIV-uninfected participants (P = 0.02) and non-INSTI-treated HIV-infected subjects (P = 0.07). Hepatic steatosis and liver disease severity global score were lower in INSTI-treated participants than in non-INSTI-treated HIV-infected participants (P = 0.05 and P = 0.04, respectively). CONCLUSIONS: HIV-infected and HIV-uninfected subjects undergoing bariatric surgery presented a similar profile regarding anthropometric measures, cardiovascular parameters, and comorbidities. However, INSTI-treated participants presented milder SCAT and liver alterations than non-INSTI-treated participants.

Dunnigan lipodystrophy syndrome: French National Diagnosis and Care Protocol (PNDS; Protocole National de Diagnostic et de Soins).

Dunnigan syndrome, or Familial Partial Lipodystrophy type 2 (FPLD2; ORPHA 2348), is a rare autosomal dominant disorder due to pathogenic variants of the LMNA gene. The objective of the French National Diagnosis and Care Protocol (PNDS; Protocole National de Diagnostic et de Soins), is to provide health professionals with a guide to optimal management and care of patients with FPLD2, based on a critical literature review and multidisciplinary expert consensus. The PNDS, written by members of the French National Reference Center for Rare Diseases of Insulin Secretion and Insulin Sensitivity (PRISIS), is available on the French Health Authority website (in French). Dunnigan syndrome is characterized by a partial atrophy of the subcutaneous adipose tissue and by an insulin resistance syndrome, associated with a risk of metabolic, cardiovascular and muscular complications. Its prevalence, assessed at 1/100.000 in Europe, is probably considerably underestimated. Thorough clinical examination is key to diagnosis. Biochemical testing frequently shows hyperinsulinemia, abnormal glucose tolerance and hypertriglyceridemia. Elevated hepatic transaminases (hepatic steatosis) and creatine phosphokinase, and hyperandrogenism in women, are common. Molecular analysis of the LMNA gene confirms diagnosis and allows for family investigations. Regular screening and multidisciplinary monitoring of the associated complications are necessary. Diabetes frequently develops from puberty onwards. Hypertriglyceridemia may lead to acute pancreatitis. Early atherosclerosis and cardiomyopathy should be monitored. In women, polycystic ovary syndrome is common. Overall, the management of patients with Dunnigan syndrome requires the collaboration of several health care providers. The attending physician, in conjunction with the national care network, will ensure that the patient receives optimal care through regular follow-up and screening. The various elements of this PNDS are described to provide such a support.

How to improve the quality of a disease management program for HIV-infected patients using a computerized data system. The Saint-Antoine Orchestra program.

OBJECTIVES: The emergence of non-AIDS-related events in the HIV-infected population experiencing a longer life expectancy implies the implementation of a comprehensive approach of HIV clinical management through better access to care, prevention, and early diagnosis of co-morbidities. METHODS: The Orchestra program is a computer-assisted HIV care and support tool implemented since December 2004 in the outpatient clinic of a University Hospital set in Paris, France. The intervention aims at improving access to HIV information care and support specifically targeted five areas of actions: cardiovascular risk factors; gynecological follow-up; anti-hepatitis B virus (HBV) vaccine coverage; sexuality and prevention of sexually transmitted infections; and compliance to antiretrovirals. The impact of this program was examined prospectively on a "before-after" basis after a two-year implementation. RESULTS: In the two-year period, 1717 patients were regularly followed. The level of the database information significantly increased in time (low density lipoprotein (LDL) cholesterol and glycemia were informed in 74% of patients at inclusion versus 95% at two years, and 83% versus 97%, p < 0.001, respectively). The number of targeted interventions was also higher. For eligible women, papanicolaou smears and mammography were prescribed in 52% of cases after intervention, versus 44% at inclusion, p0.04 and 83% versus 50%, p < 0.001, respectively. Indicators of care eventually improved significantly. Initially 72% non-adherent patients declared to be adherent after the intervention ( p < 0.001) and 67% of patients with initial LDL-hypercholesterolemia normalized their LDL level within two years ( p < 0.001). CONCLUSION: The Orchestra program has provided a unique opportunity to assess and improve prevention and management of co-morbidities in HIV patients.

[Early diagnosis and prevention of comorbidities among HIV-infected patients: the Orchestra Saint-Antoine Program]. / Dépistage et prévention des comorbidités chez les patients infectés par le VIH: le programme Orchestra Saint-Antoine.

OBJECTIVES: The Saint-Antoine Orchestra Program aims at improving the clinical management of HIV-infected patients through access to care, prevention and early diagnosis of comorbidities. METHODS: The program was initiated in December 2004 on the whole database. The following topics were concerned: cardiovascular risk factors, gynecological follow-up, anti-HBV vaccinal coverage, sexuality and prevention of STIs, therapeutic adherence and counsels to travelers. The program included several actions: diffusion of information to patients, development of a computerized chart (alert pop-ups), individualized prescription advice and recommendations for specialist referral. RESULTS: The program was applied to 1959 patients whose initial characteristics were: mean age: 43+/-10 years; ratio M/W: 1466/493; European origin: 69%; sub-Saharan: 19%; mean duration of HIV infection: 9.3+/-6 years; naïve of antiretrovirals: 14%; mean CD4+count: 494+/-277/mm(3); HIV viral load inferior to 50 cp/ml: 62%. Among 1347 patients for whom cardiovascular risk factors were completely informed, 42% had two or more factors. In particular, 31% of them were smokers, 7% had an arterial pressure superior to 140/90 mmHg and 11% had LDL-cholesterolemia superior to 4.1 mmol/l. Among 1448 untreated patients, 70% were initially considered as adherent. Half of the concerned women had neither cervical smear nor mammography up to date. Among 67% patients with an informed complete HBV serology, 27% were seronegative among which 310 (86%) were eligible for the vaccine. Problems of sexual difficulties or prevention were initially discussed for 11% of patients. Among them, 14% had a problem of prevention and 148 (66%) recognized sexual difficulties. CONCLUSION: The initiation of the Saint-Antoine Orchestra program has provided a unique opportunity to assess and improve the prevention and management of comorbidities in HIV patients. Also, this program aimed to improve professional practices.

[Low molecular weight heparin and non valvular atrial fibrillation]. / Héparines de bas poids moléculaire et fibrillation auriculaire non valvulaire.

Low molecular weight heparin (LMWH) are obtained through chemical or enzyme depolymerisation of unfractioned heparins (UFH). LMWHs present several advantages over UFH: they exhibit a smaller interindividual variability of the anticoagulant effect, they have a greater bioavailability, a longer plasma half-life and do not require monitoring of the anticoagulant effect. LMWH have restrictive indications in AF patients, cardioversion (II level C and TEE for ACC/AHA/ESC and 2C for ACCP guidelines) or use as a bridge therapy (IIB, level C for ACC/AHA/ESC). The ACE study (Anticoagulation for cardioversion using enoxaparin), showed a reduction, though not statistically significant, of 42% of the composite end point (embolic event, major bleeding and death) 2.8% under enoxaparin vs. 4.8 % under conventional treatment, relative risk 0.58, CI 95% 0.23-1.46). Other studies, using dalteparin, confirmed that an anticoagulant treatment using LMWH followed by warfarin was at least as good as conventional management. ACUTE II (Assessment of cardioversion using transesophageal echochardiography), a randomized multicenter trial, compared the efficacy and tolerance of enoxaparin (1 mg/kg every 12 hours) and UFH in 155 patients eligible for a TEE-guided cardioversion. These patients were administered LMWH or UFH for 24 hours before TEE or cardioversion. There were no significative differences regarding the incidence of the study end points, in particular stroke and bleeding, and no death occurred. HAEST (Heparin in acute embolic stroke trial), a randomized, placebo-controlled, double blind trial failed to show the LMWH superiority over aspirin in patients with acute ischemic stroke and atrial fibrillation. Finally, LMWH have been proposed as a bridge therapy in patients under chronic VKA prior to surgery or invasive procedures. This strategy resulted in a low rate of thromboembolic events and major bleedings.

Myocarditis in patients with clinical presentation of myocardial infarction and normal coronary angiograms.

OBJECTIVES: The aim of this study was to assess the diagnosis of myocarditis in patients presenting with acute myocardial infarction (MI) and normal coronary angiograms. BACKGROUND: Most often in these patients, the etiologic diagnosis remains unclear once they are found to have normal coronary arteries. The diagnosis of myocarditis mimicking MI is clinically relevant, because numerous arguments suggest a relation between myocarditis and dilated cardiomyopathy. Myocardial indium-111 (111In)-antimyosin antibody (AMA)/rest thallium-201 (201Tl) imaging allows noninvasive detection of myocarditis. METHODS: Forty-five patients admitted to three intensive care units for suspicion of acute MI, with normal coronary angiograms, were investigated. Indium-111-AMA planar images and then a dual-isotope rest AMA/201Tl tomographic study were performed. Six-month echocardiographic follow-up was obtained in 80% of the patients with initial left ventricular (LV) wall motion abnormalities. RESULTS: In eight patients, AMA and 201Tl scintigraphy were negative. In two patients, a matched 201Tl defect and focal AMA uptake suggested acute MI (due to prolonged vasospasm or spontaneously reperfused coronary occlusion). In 17 patients, diffuse AMA uptake over the whole LV suggested diffuse myocarditis. In 18 patients, focal AMA uptake with a normal 201Tl scan suggested diffuse but heterogeneous, or focal myocarditis. Complete functional recovery was observed in 81% of the patients with a pattern of myocarditis. CONCLUSIONS: Among 45 patients presenting with acute MI and normal coronary angiograms, 38% had diffuse myocarditis and 40% had a scintigraphic pattern of heterogeneous or focal myocarditis. Short-term follow-up showed complete LV functional recovery in 81% of these patients.

[Acute pulmonary edema during preterm labor: role of nicardipine tocolysis (three cases)]. / OEdème pulmonaire aigu lors d'une menace d'accouchement prématuré: rôle de la tocolyse par la nicardipine: à propos de 3 observations.

Beta adrenergic agonists are still used as first line treatment for preterm labor in many institutions, but their side effects lead to use alternative tocolytic drugs such as calcium channel blockers. We report three cases of pulmonary edema during preterm labor associated with the use of calcium channel blocker, intravenous nicardipine, widely used for tocolysis in France. In this article, potential mechanisms of this severe complication are briefly discussed: pregnancy-induced overload, deleterious hemodynamic effects of calcium channel blockers, concomitant administration of calcium channel blockers and/or beta-agonists and finally concomitant administration of physiological saline and/or glucocorticoids. Based on our experience, we recommend avoiding the association of calcium channel blockers and beta-agonists for preterm labor. Nicardipine, if used, should be administered at an adjusted dose with electric syringe to reduce volume infusion.

[Preventing cerebrovascular accidents during atrial fibrillation]. / Prévention des accidents vasculaires cérébraux dans la fibrillation auriculaire.

Atrial fibrillation, the most commonly encountered arrhythmia in clinical practice, is associated with substantial morbidity and mortality. Its incidence and prevalence are increasing, and it represents a growing clinical and economic burden. Recent research has highlighted new approaches to both pharmacological and non-pharmacological management. Pooled data from trials comparing antithrombotic treatment with placebo show that warfarin reduces the risk of stroke by 62% and that aspirin alone reduces the risk by 22%. Overall, in high-risk patients, warfarin was better than aspirin in preventing strokes, with a relative risk reduction of 36%, but the risk of major hemorrhage with warfarin was twice that with aspirin. Anticoagulation treatment needs to be tailored individually for patients on the basis of age, comorbidities, and contraindications. However, warfarin remains under-prescribed in clinical practice, for reasons related to patients (comorbidities) and physicians. The limitations of warfarin treatment have prompted the development of new anticoagulants with predictable pharmacokinetics that do not require as frequent monitoring. Ximelagatran, an oral direct thrombin inhibitor, was compared with warfarin in the SPORTIF program, which found both agents to be broadly effective in the prevention of embolic events, but observed abnormal liver function tests in 6% of patients on ximelagatran. Liver function monitoring during treatment is thus needed. Idraparinux, a factor Xa inhibitor administered by once weekly subcutaneous injections, is being evaluated in patients with atrial fibrillation. The ACTIVE trial is currently assessing the role of aspirin plus clopidogrel, compared with adjusted dose warfarin, in the prevention of vascular events in high-risk patients with atrial fibrillation. Angiotensin-converting enzyme inhibitors and angiotensin II receptor-blocking drugs interfere with atrial remodeling and show promise in atrial fibrillation, as suggested in the LIFE trial. Preliminary studies suggest that statins may reduce the risk of recurrence after electrical cardioversion. Finally, percutaneous methods for occlusion of the left atrial appendage are currently under investigation in patients at high risk of thromboembolism but with contraindications for chronic warfarin.

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.

Acute myopericarditis after diphtheria, tetanus, and polio vaccination.

We report the first case of myopericarditis after triple vaccination against diphtheria, tetanus, and poliovirus in a young adult. He presented with fever, acute chest pain, and diffuse ST-segment elevation 2 days after vaccination. Two-dimensional echocardiography findings were normal. Endomyocardial biopsy showed interstitial edema with diapedesis of erythrocytes. Laboratory findings showed inflammatory syndrome and elevated circulating immune complexes. He recovered within a few days with high-dose aspirin treatment and was without complications at 3-month follow-up. We discuss the different hypotheses for infective or hypersensitivity myocarditis.

[Thrombocytopenia after cardiac surgery due to anti-platelet allo-immunization. Apropos of a case]. / Thrombopénie après chirurgie cardiaque par allo-immunisation antiplaquettaire. A propos d'un cas.

Thrombocytopaenia is rare after cardiac surgery but carries a very high risk of bleeding and thrombotic complications. It is generally due to heparinisation but may be secondary to the surgical procedure itself (cardiopulmonary bypass, sepsis, platelet consumption by the prosthesis), or associated factors (massive blood transfusion, drug reaction, rare antiplatelet allo-immunisation). One case of post-transfusion thrombocytopenia with antiplatelet anti-HPA-la allo-antibodies with a favourable outcome with high dose polyvalent gammaglobulins is reported. The authors describe the diagnostic and therapeutic approaches to this problem.

[A new cause of increased troponin levels: junctional tachycardia]. / Une nouvelle cause d'élévation de la troponine: la tachycardie jonctionnelle.

The authors report 4 cases of acute coronary syndromes with increased troponine levels during junctional tachycardia in patients with angiographically normal coronary arteries. ST segment changes during junctional tachycardia have no predictive value for the detection of coronary artery disease. Increased troponine, a marker of myocardial cellular necrosis, is not a sign of coronary lesions. A disequilibrium between the increased metabolic and energetic requirements of the myocardium and decreased perfusion due to the tachycardia could explain this observation. The recommended management of these patients is not to perform coronary angiography initially in the absence of cerebrovascular risk factors, but rather to document myocardial ischaemia by a non-invasive method such as echocardiography or scintigraphy.

[Symptomatic left ventricular dysfunction and Behçet disease. Report of 2 cases]. / Dysfonction ventriculaire gauche symptomatique et maladie de Behçet. A propos de 2 cas.

Behçet's disease is associated with cardiac complications which may affect all three cardiac layers in 1 to 6% of cases. Although pericardial and coronary disease are the most common, the myocardium may also be affected. The clinical presentation may be left ventricular dysfunction with signs of dilated cardiomyopathy. The cause of the left ventricular dysfunction is usually coronary artery disease but it can also be inflammatory, resulting in a myocarditis with normal coronary arteries. The authors report two cases of Behçet's disease with symptomatic left ventricular dysfunction presenting as dilated cardiomyopathy with normal coronary arteries in one of the cases. Recent echocardiographic studies suggest that the incidence of myocardial disease is underestimated in this pathology: 20 to 35% of patients with Behçet's disease but no cardiac symptoms had left ventricular diastolic dysfunction. A more attentive investigation of left ventricular diastolic function in these patients should enable earlier diagnosis of this complication.

[Diagnostic strategy in acute myocarditis]. / Conduite diagnostique dans les myocardites aiguës.

Myocarditis is a focalised or diffuse disease of the myocardium. The principal causal agents are viruses in Europe and North America and a parasite in South America (Chagas' disease). The prevalence of acute myocarditis is variable, related to the periodic cycle of viral epidemics. The diagnosis is difficult to establish because the clinical presentation is variable, ranging from asymptomatic forms to rapidly fatal acute congestive heart failure. The diagnostic tools suffer from lack of sensitivity or specificity. Endomyocardial biopsy, despite its low sensitivity, remains the reference investigation as it provides histological proof of the myocarditis. Myocardial scintigraphy with antimyosin antibodies has the advantage of very good sensitivity but with less specificity. The authors discuss the critical indications and limitations of each investigation.

[Comparative incidence of protrusive atheromatous plaques of the thoracic artery in patients with atrial fluter and atrial fibrillation]. / Fréquence comparée des plaques athéromateuses protrusives de l'aorte thoracique chez les patients en flutter et en fibrillation auriculaire.

Although it has been demonstrated recently that in patients with atrial fibrillation, protrusive atheromatous plaques of the thoracic aorta (thickness 4 mm) and left atrial abnormalities such as thrombosis, spontaneous contrast and low atrial blood flow velocities carry an additional embolic risk, this has not yet been studied in atrial flutter. Out of 2493 patients undergoing transoesophageal echocardiography between September 1993 and December 1997, 271 consecutive patients in atrial flutter (N = 41) or fibrillation (N = 230) for over 48 hours, underwent transoesophageal echocardiography before cardioversion. Patients with atrial flutter were compared with those with atrial fibrillation. Their characteristics were comparable with respect to age (68 +/- 13 and 67 +/- 12 years respectively, p = 0.628), sex ratio (men 66 and 54% respectively, p = 0.212), previous thromboembolic disease (5 and 15% respectively, p = 0.126). The incidence of protrusive aortic atheroma (12 and 11% respectively, p = 0.919), of spontaneous contrast in the thoracic aorta (15 and 14% respectively, p = 0.847) were identical in both groups. The left atrium was significantly smaller (3.1 +/- 0.7 and 6 +/- 3 cm2 respectively, p = 0.001), spontaneous atrial contrast less frequent (17 and 37% respectively, p = 0.024) and the velocities of atrial emptying higher (47 +/- 10 and 30 +/- 10 cm/s respectively, p = 0.030) in patients with flutter compared with atrial fibrillation. There was no difference in left ventricular fractional shortening (30 +/- 10 and 33 +/- 13% respectively, p = 0.630), the presence of rheumatic valvular disease (5 and 12%, p = 0.301), left atrial diameter (43 +/- 7 and 45 +/- 8, p = 0.134), right atrial surface area (16 +/- 4 and 17 +/- 6 cm2, p = 0.384) or in intraatrial thrombosis (2 and 3%, p = 0.888) respectively. These results show a high prevalence of protrusive atheroma of the thoracic aorta both in atrial flutter and in atrial fibrillation, and fewer left atrial abnormalities in patients with flutter.

[Does Doppler analysis of hepatic venous flow predict increased right atrial pressure and right ventricular dysfunction?]. / L'analyse doppler du flux des veines sus-hépatiques permet-elle de prédire le niveau de pression auriculaire droite au cours de l'infarctus du ventricule droit?

The aim of this study was to test the hypothesis that Doppler study of hepatic venous flow, reflecting right atrial pressures and right ventricular dysfunction, allows prediction of increased right atrial pressure and right ventricular dysfunction in patients with right ventricular infarction. The authors studied 30 patients (27 men, mean age 54 +/- 12 years) in sinus rhythm with acute inferior myocardial infarction who underwent right heart catheterisation and Doppler echocardiography including recording of regurgitant and hepatic vein flow within 48 hours of hospital admission. Hepatic venous flow was used to measure peak velocity and velocity time integrals (VTI) of the systolic (S), diastolic (D) and atrial (a) contraction waves. The fraction of systolic filling was calculated: VTI S/VTI S + VTI D. The pressure half-time of pulmonary regurgitant flow (PHT IP) was also measured. Using haemodynamic criteria (non-compliant right atrial pressure wave form or right ventricular end diastolic pressure/pulmonary capillary pressure > or = 0.8), patients were divided into two groups: Group 1: right ventricular infarction (VD+, N = 22). Group 2: no right ventricular infarction (VD-, N = 8). No correlation was observed between Doppler parameters of hepatic venous flow and haemodynamic data, in particular right atrial pressure and pressure wave form. Moreover, no statistically significant difference was observed between the two groups with respect to the Doppler parameters derived from hepatic venous flow. On the other hand, the results confirmed good diagnostic performance of Doppler analysis of pulmonary regurgitant flow: sensitivity 80%, specificity 83%, positive predictive value 94%, negative predictive value 55%. The authors conclude that, in patients with acute inferior wall infarction, Doppler analysis of hepatic venous flow does not allow assessment of right atrial pressure or of ischaemic right ventricular dysfunction.

[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.

[Management of the cardiovascular complications of treatment in thoracic oncology]. / Prise en charge des complications cardiovasculaires des traitements en oncologie thoracique.

The management of patients suffering from bronchial and lung tumors depends on conventional chemotherapy and/or targeted molecular therapies. The prescription of these chemotherapies may be accompanied by cardiovascular complications, principally congestive heart failure, arterial hypertension and arterial or venous thrombo-embolism, the frequency of which varies with the molecule administered. The management of these complications is currently poorly standardized and should take account of the patient's oncological prognosis.

Effects of HIV protease inhibitors on cardiac conduction velocity in unselected HIV-infected patients.

We examined the prevalence and the extent of prolongation of the PR and QRS intervals and their relation to anti-HIV treatments and other clinical characteristics in 970 HIV-infected patients, 749 treated with antiretroviral therapy and 221 untreated. Age, body mass index, heart rate, and treatment with ß-blockers and HIV protease inhibitors (PIs) were independent predictors of increase in the duration of the PR interval. Male gender, Caucasian ethnicity, heart rate, duration of antiretroviral therapy, and use of PIs were independent predictors of an increase in the duration of the QRS interval. Users of HIV PIs had an adjusted QRS-interval duration that was 2.6 ms (95% confidence interval (CI) 1.4-3.9) longer than the interval in nonusers (P = 0.0004). The adjusted odds ratios of first-degree atrioventricular block (n = 54) and complete bundle branch block (n = 23) were 1.62 (95% CI 0.90-2.89; P = 0.10) and 2.71 (95% CI 1.10-7.13; P = 0.03), respectively, in patients taking PIs. These findings may have important clinical implications, particularly with respect to QRS prolongation in patients with myocardial ischemia or heart failure.