The effects of talking, reading, and silence on the "white coat" phenomenon in hypertensive patients.

To explore the mechanisms of the "white coat" phenomenon, the effects of talking, reading, and silence were analyzed. Fifty essential hypertensive patients were randomly allocated to periods of stress talking and relaxing reading, alternating with three periods of silence. While talking, systolic/diastolic blood pressure increased sharply, from 142 +/- 0.7/97.7 +/- 0.5 mm Hg to 159 +/- 0.7/111 +/- 0.5 mm Hg (P < .0001). While reading, systolic/diastolic blood pressure decreased (P < .0001). Moreover, talking and reading had opposite residual effects. The silence and reading periods gave the best approximations of the daytime ambulatory period. The predictive value of clinical blood pressure can be improved if measured during a period without talking, thus decreasing the "white coat" phenomenon.

The heparin management test: a new device for monitoring anticoagulation during coronary intervention.

Whole blood coagulation analysers are widely used during percutaneous coronary interventions. The precise degree of anticoagulation in patients is important in this setting. The aim of this investigation was to compare the results obtained with ACT (Hemochron) and HMT, the Heparin Management Test (TAS) in patients undergoing percutaneous coronary interventions. Patients (n = 100) were enrolled prospectively. Each patient received 10,000 units of heparin. At the end of the procedure, the mean ACT was 284+/-31 seconds and the mean HMT was 292+/-33 seconds. The correlation between the two methods was highly significant (r = 0.64, p<0.001). The HMT correlates well with ACT values in patients undergoing percutaneous coronary interventions. Its use in the management of these patients should be considered.

Talking effect and "white coat" effect in hypertensive patients: physical effort or emotional content?

Talking has been shown to increase blood pressure instantaneously in hypertensive patients and to contribute to the white coat effect. The effects of talking were compared with those of counting aloud in 64 patients with essential hypertension who were randomly assigned to a period of stress talking and a period of counting aloud (active periods), alternating with three periods of silence (control). The same monitor was used for office measurements and 24-hour ambulatory blood pressure analysis. Systolic/diastolic blood pressures increased significantly more during talking (163/110 mmHg) than during counting aloud (152/102 mmHg, both p < .0001) in both treated and untreated patients and in sustained and clinical hypertension. Talking had a residual effect on systolic blood pressure that lasted 5.8 +/- 0.1 minutes. The emotional content seemed to be the only cause of the talking effect. Its instantaneous and residual effects on blood pressure and heart rate should be considered when measuring these variables.

Talking effect and white coat phenomenon in hypertensive patients.

Both white coat effect (the tendency of blood pressure to rise during a medical visit) and talking effect were analyzed in 42 patients with essential hypertension. Blood pressure was measured during the clinic visit and over the subsequent 24-hour ambulatory period, with the physician performing 49 +/- 4 measurements for each patient. Three silent periods and two talking periods (stress and relaxation) were randomly allocated in a crossover design and studied, using analysis of variance. During the initial 11-minute silent period, systolic/diastolic blood pressures increased by 6 mm Hg/5 mm Hg. During the subsequent talking periods, these variations were significantly greater: +22 mm Hg/+17 mm Hg. Measures of systolic/diastolic blood pressure were higher during stressful talking than during relaxed talking. The talking and its emotional contents seemed to explain 70% of the white coat phenomenon. To minimize the white coat phenomenon in the clinic, physicians, nurses, and clinicians are advised to measure blood pressure during an initial period of silence.

[Phonomechanography of recent myocardial infarct: the jugulogram and carotidogram]. / Phonomécanographie de l'infarctus du myocarde récent: Le jugulogramme, le carotidogramme

The mechanographic tracings of 30 patients with recent myocardial infarction, usually uncomplicated and without mitral incompetence, were compared with those of two control groups. The jugular venogram was unhelpful; full measurements can be made in only 40% of cases, and the scatter of normal values is too great. The carotid arteriogram is usually of the "arterial" type. Transmission time and the duration of the rising phase were both shortened. These findings result from the high level of peripheral resistance. The mean left systolic time was, except for qB2, abnormal, and remained so at the end of the first month. In this series there were neither maximal changes in J3, nor significant improvement from J12 nor J30. The largest increases in PPE and PPE/LVET were found in cases with large infarcts, and the largest reduction of LVET was in a case with left ventricular failure. There was no particular peculiarity corresponding with the site of the necrosis. Alteration in the ratio PPE/LVET is often a lasting measure of depressed left ventricular function. It would be most useful to study this ratio in the long term and to use it as a measure of recovery of function and as a guide to advising the patient on his future life style.

[Study of changes in myocardial contraction and left ventricular diastolic regidity after aortocoronary bypass]. / Etude des modifications de la contractilité myocardique et de la rigidité diastolique ventriculaires gauches après pontage aorto-coronarien

Eighteen patients with coronary insufficiency underwent a left ventricular cineangiography before and an average of four months after aorta-to-coronary bi-pass in order to assess the post-operative changes of myocardial contractility and diastolic rigidity. The contractility indices (VCF: mean speed, and VCF max: maximum shortening speed of the equatorial diameter of the left ventricle (% delta theta) were unmodified in the group (I) of fourteen patients with at least one pervious by-pass. On the contrary, a decreased % delta theta was observed in the group (II) of four patients in whom all the by-passes were occluded. The left ventricular end-diastolic pressure (LVEDP), the end-diastolic volume (LVEDV) and the "normalized" rigidity index (K) were unmodified in both groups after operation. The cardiac rate increased in the post-operative period in the group I (p less than 0.01) and the whole of the 18 patients (p less than 0.001); there was a positive correlation (p less than 0.02) between this variation and that of VCF, VCF max. and % delta theta, the significance of which is discussed. Besides there was a negative correlation between the variations of LVEDV and the VCF, and between the equatorial end diastolic diameter of the left ventricle and VCF, VCF max. and % delta theta, both in the pre-operative and the post-operative periods.

[Phonomecanography in recent myocardial infarction. Ventricular mechanic curve]. / Phonomécanographie de l'infarctus du myocarde récent. la courbe mécanique ventriculaire

Repeated recordings were made of the apexcardiogram throughout the first month after myocardial infarction in 30 patients. The classical timed intervals of the systolic wave are open to some criticism. The systolic waveforms are important. In the majority of transmural anterior infarctions there is a rounded appearance to the beginning of the wave which seems to prolong the electromechanical latency, followed by a late systolic bulge, or a domed waveform. This signifies a non-contractile area, and not neccessarily an ectasia. The early diastolic "peaktrough" appearance, found very frequently wherever the necrosis is situated, is indicative of asynergic contraction of the left ventricle. All of the diastolic phases are altered, probably by increased parietal stiffness: the TRI is lengthened; the "F" wave is flattened (and often absent later on in the condition), its duration is shortened over the anterior positions, and it may contain a shallow dip if there is LVF; the stasis wave is very feeble; the "a" wave is large when the infarct is extensive, or when there is LVF, or when there is longstanding hypertension. Enlargement of the "a" wave is especially indicative of a lowering of the performance of the left ventricle.

[Optimum flow of intravenous trinitrine during the acute stage of myocardial infarct with cardiac insufficiency: its effects on survival]. / Le débit optimal de trinitrine intraveineuse au stade aigu de l'infarctus du myocarde en insuffisance cardiaque. Action sur la survie.

Twenty-one patients were treated during the acute stage of a myocardial infarction for failure of the left or right ventricle. The systematic use of varying rates of flow of intravenous trinitrin (between 0.6 and 4.8 mg/h) was designed to find out for each patient the optimal effect on the cardiac index. The fall in pulmonary capillary pressure, obtained within 10 to 15 minutes, is proportional to the flow rate of trinitrin, and reaches 48% of its original value at a perfusion rate of 4.8 mg/h. The lowering of systemic arterial pressure is also proportional to the flow rate, and reaches 13% at a flow of 4.8 mg/h. The cardiac index and systolic index were significantly improved at flow rates of 1.2 to 2.4 mg/h, and lowered the pulmonary capillary pressure to levels of 17.6 mm of mercury and 15.3 mm of mercury respectively. Trinitrin given intravenously is very well tolerated, but it often become less effective after 24 hours of treatment, which implies that haemodynamic measurements must be made several times a day, and the speed of infusion often increased. The improvement in immediate and late prognosis is discussed relative to the initial values and Weber's index of survival.

[Doppler echocardiographic evaluation of aortic valve prosthesis. Analysis of the reproducibility of pressure gradients and surface measurements]. / Evaluation des prothèses valvulaires aortiques par échocardiographie Doppler. Analyse de la reproductibilité des measures de gradients et de surfaces.

Doppler echocardiography has become the method of choice for the evaluation of cardiac valve prostheses. In order to determine the reproducibility of the measurements of pressure gradient and valve surface area, 55 patients with aortic valve prostheses without clinical dysfunction and having at most a trivial regurgitation on color Doppler examination underwent a double evaluation during an average interval of 9 +/- 5 months. The maximum and mean pressure gradients were recorded and the valve surface area calculated using the continuity equation in all cases. The subaortic diameter was taken to be constant and equal to the external diameter of the prosthesis. No significant differences were found between the two evaluations of mean pressure gradient and valve surface area. The intra-patient variability was +/- 8 mmHg for the maximum pressure gradient, +/- 6 mmHg for the mean pressure gradient, +/- 0.33 cm2 for valve surface area calculated using the maximum velocities and +/- 0.44 cm2 when the velocity-time integrals were used. When expressed as a percentage, the mean coefficient of variation was 21 +/- 17% for the maximum pressure gradient, 21 +/- 18% for the mean pressure gradients, 21 +/- 15% for the valve surface area calculated using the maximum velocities and 22 +/- 14% when the ratio of velocity-time integrals was used.(ABSTRACT TRUNCATED AT 250 WORDS)

[Sinus node function in man. Statistical analysis]. / Etude de la fonction sinusale chez l'homme. Analyse statistique

The sinus function of 60 patients was studied by atrial stimulation at a fixed rate, and also at a rate linked with the preceding sinus cycle. These patients were divided into 3 groups according to the surface-recorded ECG; 10 had clear evidence of sinus dysfunction, 23 had an isolated sinus bradycardia, and 27 were considered as controls a their sinus rate was above 60/min., with a normal PR interval. Calculation of the limits of tolerance showed that at the 5% level, 95% of the values for all the controls fell between 96.8 and 568.7 ms for the corrected post-stimulatory pause, and between 114.5 and 434.3 ms for the corrected maximum return cycle. A study of the distribution zones of the graph CT/CR-AA/AA proved that an absent zone II is a pathological finding. In the group of sinus bradycardias the limits of what constitutes pathology are less clear, and the situation is not improved by noting whether atrial "echos" are present or absent. Because there is a narrow positive correlation between the values given by the two methods, the physio-pathology of sinus dysfunction can be discussed.

[Radioisotope measurement of coronary flow with atrial stimulation in the normal subject and in patients with coronary disease]. / Mesure radio-isotopique du débit coronaire avec stimulation auriculaire chez le sujet normal et le coronarien

The induction of atrial systole by stimulation is a means of demonstrating insufficiency of myocardial perfusion, even where there is a normal coronary flow under basal conditions in a genuine case of coronary atherosclerosis. The method, which entailed the use of radiocardiography with potassium 42, was first checked for reproducibility. The coronary flow was then measured under basal conditions, and subsequently during or after atrial stimulation at 150/min. in a group of 50 controls and coronary patients. Under atrial stimulation, the value increases by an average of 15 per cent in the controls, and decreases by an average of 32 per cent in cardiac patients with vessels which are patent on coronary angiography. The coronary moiety of the cardiac output increases by an average of 27 per cent in the controls, but does not change significantly in the coronary group. After aorto-coronary by-pass, the coronary moiety of the cardiac output is increased significantly during stimulation when the by-pass is patent.

[The end-diastolic pressure-volume relationship of the left ventricle. Significance for the indices of compliance and diastolic rigidity of the ventricle]. / La relation pression-volume télédiastolique du ventricule gauche. Conséquences sur les indices de compliance et de rigidité diastoliques ventriculaires.

In order to evaluate the importance of the indices of ventricular rigidity and compliance (k=dP/dV.P and dV/dP), three groups of patients were studied and compared. A simplified method of calculating the diastolic compliance made use of the values of end-diastolic volume (EDV) measured by cineangiography, and of end-diastolic pressure (EDP), using the assumption that the relationship P-V is an exponential one arising from the ordinate: 0.43 mmHg. The correlation between EDP and EDV, which was positive in 19 coronary artery patients, was in fact negative in 11 patients with obstructive cardiomyopathy (OCM), and insignificant in 12 control patients. There were multiple correlations between k, EDPs and EDVs in 11 OCMs, and none in the two other groups. The ratio dV/dP decreased in end-diastole both in the OCM group and in the coronary group, and did not reflect the difference in pathology between these two groups. On the other hand k was increased in the patients with OCM, normal in the coronary patients, and represented in the former a primary modification in the relationship P-V and a primary increase in diastolic rigidity.

[Phonomechanographic evaluation of the severity of pulmonary stenosis]. / Evaluation phonomécanographique de la sévérité des rétrécissements pulmonaires.

External phonomechanographic methods allow us to obtain a fairly precise estimate of the degree of obstruction to the pulmonary outflow, whether such an obstruction is a single entity or associated with another intracardiac malformation. The greatest precision in this field is obtained with the cases of pure pulmonary stenosis. The findings on phonomechanographic investigation of 54 cases with pulmonary stenosis have been compared with the results of the haemodynamic tests (catheterisation and angiography) as well as with the anatomical findings after a surgical cure had been effected in a certain number of cases. This study has allowed us to pick out five phonomechanographic criteria of severity of pulmonary stenosis: an increased reduplication of the second sound, lenghening of the interval between the Q wave of the electrocardiogram and the maximum portion of the systolic murmur, an increase in Furuta's ratio and also in the amplitude of the jugular venous a-wave as a function of the total height t (the a/t ratio), but most especially the "corrected" Furuta ratio as a function of the length of the ejection phase of the right ventricle, as this has been shown to possess the best correlation with the right ventricular systolic pressures.

[Comparison of 24 hours ambulatory electrocardiography and endocavitary recording in the diagnosis of heart rate disorders]. / Confrontation de l'enregistrement continu ambulatoire de l'électrocardiogramme des 24 heures et des explorations endocavitaires dans le diagnostic des troubles du rythme cardiaque.

Ninety symptomatic patients aged between 16 and 90 years were investigated by ambulatory continuous 24 hour electrocardiography. 75 of these patients underwent endocavitary exploration of atrioventricular conduction and sinus node function within 48 hour of ambulatory electrocardiography. Symptoms occurred during the recording in 30% patients, enabling the mechanism of the malaise to be determined. Every time that abnormalities in the zone surrounding the Tawara node were demonstrated by endocavitary recordings, the 24 hour electrocardiogramme showed the symptoms to be due to other causes than complete heart block. In 70% patients no symptoms were experienced but 58% of them had cardiac arrhythmias and particularly sinus node dysfunction (24 out of 37 patients) on the 24 hour electrocardiogramme. Comparing the results of these two methods of investigation, continuous electrocardiography appears to be a better technique for the diagnosis of sinus node dysfunction but endocavitary study of sinus node function would seem more suited to determine its severity. Endocavitary recordings seem more reliable in the investigation of paroxysmal atrioventricular blocks. These results demonstrate the complementary nature of these two methods in determining the causes of syncope and dizziness.

[Value of early vasodilator treatment with prazosin in chronic cardiac insufficiency]. / Intérêt du traitement vasodilatateur précoce par la prazosine au cours de l'insuffisance cardiaque chronique.

The purpose of the present study was to find out whether the beneficial effect of prazosin in congestive heart failure persists after 2 and 6 months of treatment and whether the clinical and haemodynamic data obtained correlate with the response to treatment. Twenty-four patients of mean age 50.0 +/- 3.00 years presenting with congestive heart failure stage II (3 cases), stage III (18 cases) or stage IV (3 cases) in the NYHA functional classification were treated. All abstained from taking digitalis at least one week before treatment and were given prazosin 14.5 +/- 0.77 mg/day together with spironolactone 25 to 100 mg/day. The results of treatment were assessed by its effects on echocardiography, systolic time intervals, ejection fraction and cardiac index measured by the radioisotope method, and maximal duration of a 60-watt exercise on an ergometric bicycle. Treatment was discontinued before the 6th month in 9 out of 10 non-responders. The remaining 14 patients responded to treatment and their condition improved. Mean blood pressure rose in 6 months from 95.4 +/- 3.92 to 104 +/- 3.06 mmHg (p less than 0.05). The cardiothoracic ratio was reduced at 2 months (-0.05 +/- 0.01, p less than 0.01) and at 6 months (-0.08 +/- 0.02, p less than 0.01). Systolic time intervals were not significantly altered.(ABSTRACT TRUNCATED AT 250 WORDS)

[Contractility and diastolic complicance of the left ventricle in patients with coronary insufficiency without myocardial necrosis]. / Contractilité et complicance diastolique du ventricule gauche des insuffisants coronariens sans nécorse myocardique

The 19 coronary patients studied were found to have a "normalised" rigidity k = dp/(dVP) identical to that of normal subjects, and a lowered instantaneous end-diast-lic compliance (dV/dP)TD. The increase in end-diastolic pressure is due to a small increase in end-diastolic volume, and brings about Starling's phenomenon to compensate for a diminution in contractility. The maximimum speed of shortening of the myocardium (VCFmax) shows up the baseline contractility, and appears to be more sensitive than the mean speed of myocardial shortening (VCF) and the ejection fraction.

[Enhancement of the effect of captopril in the 1st 48 hours of treating refractory heart failure. A comparison with intravenous trinitrine]. / Amélioration de l'effet du captopril au cours des 48 premières heures de traitement de l'insuffisance cardiaque réfractaire. Comparaison avec la trinitrine intraveineuse.

The favourable haemodynamic effects of vasodilator drugs in refractory cardiac failure sometimes alter rapidly after the initial dose. This tachyphylactic phenomenon was looked for during captopril therapy in 14 patients with chronic cardiac failure resistant to digitalo-diuretic therapy and conventional vasodilator drugs. The average age of the patients was 64,4 +/- 3,8 years. Eleven patients had signs of congestive cardiac failure while the remaining three patients had only left ventricular failure. Four patients were classified as Stage III and the other ten Stage IV of the NYHA classification. Right heart catheter studies were performed with a Swan Ganz catheter and systemic pressures were measured by femoral artery catheterisation. Right and left pressures and cardiac output were measured under basal conditions, and 1 and 5 hours after a single dose of captopril (early and late periods). Captopril was given in between meals in 3 to 6 daily doses; in 10 of the 14 cases the dose was 50 mg 6 hourly. The haemodynamic parameters were recorded again during the early and late periods after the dose of captopril 24 and 48 hours after starting therapy. Captopril is a mixed vasodilator and is effective from the first hour of administration. It preferentially lowered pulmonary capillary pressure (PCP) from 29,6 +/- 0,92 mmHg to 21,4 +/- 1,04 mmHg (delta PCP: -27,7%, p less than 0,01). Mean systemic blood pressure (MBP) fell less from 92,4 +/- 3,51 mmHg to 76,6 +/- 3,4 mmHg (delta MBP: -17%, p less than 0,01).(ABSTRACT TRUNCATED AT 250 WORDS)

[New thrombolytic agents in myocardial infarction]. / Nouveaux agents thrombolytiques dans l'infarctus du myocarde.

Myocardial infarction is the result of thrombotic coronary artery occlusion. Although present-day thrombolytics have major value by increasing the frequency of reopening of arteries responsible for myocardial infarction, by preserving myocardial function and, thereby, significantly reduce mortality. Nevertheless, they are subject to the following limitations: 1) excellent arterial partency is only obtained in 50% of cases: 2) reocclusion occurs in 5 to 10% of cases; 3) severe complications such as cerebral haemorrhage are observed in about 0.5% of cases. Therefore, the search to improve thrombolytic agents is intense. This article reports the recent advances in concept and production of new thrombolytic agents. The most recent results concern the production of mutants of T-PA (tissue plasmogen activator). Of these mutants, the reteplase (r-PA) has already received authorization for its commercialisation. Other t-PA mutants under development (phase 3) include TNK-t-PA and lanoteplase. Over the last few years, there has been renewed interest in staphylokinase. The results of the initial clinical trials with this agent have also been reported. Paradoxically, the mode of action of thrombolytic agents has an inherent pro-thrombotic effect. This explains some of the interest for anti-thrombotic agents as an adjuvant treatment of thrombolysis. The initial results of the association of thrombolytics with new glycoprotein IIb/IIIa platelet inhibitors and anti-thrombin agents are reported.

[Postinfarction segmental asynergy: correction after angioplasty. Predictive value of exercise thallium scintigraphy]. / Asynergie segmentaire postinfarctus: correction après angioplastie. Valeur prédictive de la scintigraphie au thallium d'effort.

The aim of this study was twofold: to evaluate the frequency of reversibility of segmental post-subendocardial infarction asynergy after coronary angioplasty, and to test the predictive value of the redistribution phenomenon during stress Thallium scintigraphy with respect to the reversibility of segmental asynergy. The inclusion criteria for this study were: previous postsubendocardial myocardial ischaemia with residual resting or effort ischaemia documented with or without the Thallium test, segmented asynergy documented by quantitative analysis of the ventriculography, complete correction of coronary angioplasty of stenotic single or double vessel disease, a balanced coronary distribution or dominant left coronary in cases of lesion of the circumflex artery. Out of 254 consecutive angioplasty procedures 39 patients met these inclusion criteria. The location of the subendocardial infarct (SEI) was anterior in 17 cases and inferior in 22 cases. The study protocol included a Thallium scintigraphy from the 10th day after SEI, ventriculography 24 hours later, angioplasty and control ventriculography 24 hours after angioplasty. Comparison of the two ventriculographies opposed Group A (reversible asynergy) and Group B (irreversible asynergy) according to criteria defined in 15 normal subjects whose average regional ejection fraction (REF) was 0.53 +/- 0.11. This result enables definition of normal segmental motion if the REF greater than 0.30 (mean--2 SD); hypokinetic if the REF greater than 0.30 or akinetic if the REF less than 0.10 (mean--4 SD). An increase of REF of 0.15 (50% of the minimal normal value) allowed definition of reversibility of asynergy. By these criteria, 19 patients (48.7%) had reversible asynergy after PTCA; 20 had definitive asynergy (51.3%).(ABSTRACT TRUNCATED AT 250 WORDS)

[Holter electrocardiography before and after coronary angioplasty. Angiographic correlation after 24 hours and 6 months]. / Electrocardiogramme Holter avant et après angioplastie coronaire. Corrélations angiographiques à 24 heures et à 6 mois.

Myocardial ischaemia was searched for by Holter monitoring before and after coronary angioplasty with primary success in 31 patients. Control angiography was performed at 24 hours and 6 months after angioplasty. Twelve patients had signs of myocardial ischaemia before angioplasty (cumulated ischaemia: 743 minutes). The degree of coronary stenosis was 92 +/- 6% before angioplasty, 25 +/- 17% immediately after the dilatation increasing to 34 +/- 25% at the 24th hour (p less than 0.002). Despite successful angioplasty myocardial ischaemia persisted in 6 patients (cumulated ischaemia: 184 minutes) and was silent in 5 of the 6 cases. In these 6 cases, control angiography at 24 hours showed either a dissection (n = 4) or a filling defect (n = 2). The angiographic outcome of the postangioplasty stenosis and at 24 hours was the same in Group I without restenosis (25 +/- 14% versus 33 +/- 22%) as in Group II with restenosis (25 +/- 22% versus 37 +/- 30%). In Group I, the degradation of the result at 24 hours was reversible at 6 months (33 +/- 22% vs 23 +/- 14%). After angiographic success, postangioplasty ischaemia present in 20% of cases was frequently silent. No correlation was observed with restenosis at 6 months which raises the possibility of a reversible microthrombotic etiology. These results justify antiaggregant and anticoagulant therapy in the 48 hours following angioplasty.